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: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 1133.250000 42147.5000 37.1917
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 86 54.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 692 1756.750000 65292.7500 37.1668
Subtotal (Total Children Is Unduplicated) 1212 2944.250000 107440.2500 36.4916
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 24 54.000000 2700.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 6 14.000000 700.0000 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
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 57.727599 4329.5700 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 17.333333 1300.0000 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 9 18.000000 1350.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 50.000000 2775.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 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) 111 270.555193 16793.7200 62.0713
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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 10624.108869 251607.1300 23.6827
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Number of Children (Unduplicated) With at Least One Service 1303
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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 5456 6517.953489 115481.9600 115481.9600
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
5932 4106.155380 136125.1700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11388 10624.108869 251607.1300 115481.9600