CMS/EIP Fiscal Report Center: 55
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 961 1004.000000 37339.4000 37.1906
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 85 53.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 577 1464.250000 54422.2000 37.1673
Subtotal (Total Children Is Unduplicated) 1077 2521.500000 91761.6000 36.3917
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 21 44.000000 2200.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 5 10.000000 500.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 8 13.000000 650.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 42.394266 3179.5700 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 13.333333 1000.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 34.000000 1887.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 1.494261 76.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 359.8700 51.4100
Subtotal (Total Children Is Unduplicated) 87 199.221860 12183.7200 61.1565
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 20.0000 20.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 8.000000 400.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 43 40.000000 2000.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 9 11.500000 575.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 27 34.500000 862.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 15.500000 775.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 27 57.000000 1425.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 40 37.500000 1875.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 8 9.500000 475.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 23 21.500000 537.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 11.000000 550.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 109 643.250000 32162.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 8 30.000000 1500.0000 50.0000
INTR-T1013-INTERPRETER 1 2.500000 270.0000 108.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 543 4521.000000 45210.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 83.129935 5982.0300 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 24 120.685243 6951.4700 57.6000
PHY-97110-PT SESSION BY LICENSED PT 19 96.394934 6936.5800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 13 70.959869 4084.4500 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 195.383695 14059.8100 71.9600
TRAV-TRAVS-Travel by mile 33 1397.000000 621.3200 0.4448
Subtotal (Total Children Is Unduplicated) 599 7409.303676 127373.1600 17.1910
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Total 10130.025536 231318.4800 22.8349
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Number of Children (Unduplicated) With at Least One Service 1168
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Center 55
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 5440 6485.953489 113287.9600 113287.9600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5344 3644.072047 118030.5200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10784 10130.025536 231318.4800 113287.9600