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
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 1074 1133.500000 42156.8000 37.1917
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 86 54.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1208 3952.000000 146861.0000 37.1612
Subtotal (Total Children Is Unduplicated) 1296 5139.750000 189017.8000 36.7757
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 28 61.000000 3050.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 6 14.000000 700.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 12 20.000000 1000.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 32.000000 2400.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 178 360.500000 27037.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 30 60.000000 4500.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 46.000000 3450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 52.000000 3900.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 17 34.000000 2550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 89 180.000000 9990.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 19 38.000000 2109.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 20 20.999999 1079.6100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 24 24.000000 1233.8400 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 6 6.000000 308.4600 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 6.000000 308.4600 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 18 18.000000 925.3800 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
Subtotal (Total Children Is Unduplicated) 345 1026.499999 68240.9800 66.4793
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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 291 1933.500000 96675.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 22 112.500000 5625.0000 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 96 536.750001 38624.5300 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 8.000000 575.6800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 129 994.015103 57255.2700 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 4.000000 230.4000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 2 26.000000 1497.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 60 446.499986 32130.1400 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 7.000000 503.7200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 61 400.750000 23067.1700 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 166 911.249998 65573.5500 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 9.750000 701.6100 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 37.000000 2662.5200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
TRAV-TRAVS-Travel by mile 33 1397.000000 621.3200 0.4448
Subtotal (Total Children Is Unduplicated) 642 11597.51509 380890.4700 32.8424
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Total 17763.765087 638149.2500 35.9242
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Number of Children (Unduplicated) With at Least One Service 1334
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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 2053 1819.250000 80171.9100 0.0000
P 6666 7689.453489 171262.5300 171262.3800
D 0 0.000000 0.0000 0.0000
S 1 1.333333 100.0000 0.0000
H 48 72.500000 5126.5900 0.0000
T 0 0.000000 0.0000 0.0000
9970 8181.228265 381488.2200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18738 17763.765087 638149.2500 171262.3800