CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 392 163.500000 6082.1000 37.1994
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 25 14.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 300 868.750000 32118.4500 36.9709
Subtotal (Total Children Is Unduplicated) 579 1046.250000 38200.5500 36.5119
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
Subtotal (Total Children Is Unduplicated) 4 20.000000 1383.0000 69.1500
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 45 51.000000 2550.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 55 54.500000 2725.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 16 14.500000 362.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 52 79.250000 3962.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 6 5.750000 287.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.250000 6.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 26 32.000000 1600.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 5 2.500000 125.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 24 57.500000 2875.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.750000 87.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 34 42.500000 2125.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 135 184.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 29.500000 1475.0000 50.0000
INTR-T1013-INTERPRETER 1 1.500000 75.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 503 2904.000000 29040.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 3.000000 215.8800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 0.750000 53.9700 71.9600
PHY-97110HM-PT SESSION BY PT ASST 1 7.000000 402.9200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 4.750000 341.8100 71.9600
TRAV-TRAVS-Travel by mile 403 25117.00000 11175.2300 0.4449
Subtotal (Total Children Is Unduplicated) 655 28596.25000 59573.5600 2.0833
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Total 29662.500000 99157.1100 3.3428
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Number of Children (Unduplicated) With at Least One Service 902
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Center 52
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 30 34.250000 1849.3000 0.0000
S 10 3.500000 129.8500 0.0000
H 0 0.000000 0.0000 0.0000
T 3037 28221.000000 55911.6400 55210.7000
2146 1402.750000 41229.1200 80.0000
Other 1 1.000000 37.2000 0.0000
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Total 5224 29662.500000 99157.1100 55290.7000