CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 611 256.500000 9541.8000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 173 149.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 564 1546.500000 57529.8000 37.2000
Subtotal (Total Children Is Unduplicated) 919 1952.750000 67071.6000 34.3473
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.500000 112.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 6.500000 487.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 9.500000 527.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 13.000000 975.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 33 52.000000 3900.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.000000 487.5000 69.6429
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 30 51.500000 3862.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 28.000000 2100.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 42 66.500000 4987.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 96.000000 5328.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 52 85.500000 4745.2500 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 7 7.000000 359.8700 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 8.000000 359.9000 44.9875
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 36.8300 36.8300
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 318.5500 45.5071
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 31.9700 31.9700
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 4 12.000000 572.4200 47.7017
Subtotal (Total Children Is Unduplicated) 191 478.500000 30854.6800 64.4821
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 84 74.750000 3737.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 17 16.750000 837.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 13 12.500000 312.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 97 141.750000 7087.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 6 4.500000 225.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 13 5.500000 137.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 47 63.000000 3150.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 40 40.000000 2000.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 15 12.000000 600.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 8 8.250000 412.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.250000 6.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 32 25.750000 1287.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 13 11.500000 575.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.500000 12.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 32 108.500000 5425.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 194 1011.500000 50575.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 5.500000 275.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 579 3669.000000 36690.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 148.750000 9729.6700 65.4095
PHY-97110-PT SESSION BY LICENSED PT 14 25.750000 1358.6200 52.7619
PHY-97110GT-PT SESSION BY LICENSED PT 3 7.000000 443.7200 63.3886
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 140.500000 8986.6700 63.9621
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 318.9200 63.7840
TRAV-TRAVS-Travel by mile 520 55633.00000 24710.9400 0.4442
Subtotal (Total Children Is Unduplicated) 617 61172.00000 158907.2900 2.5977
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Total 63603.250000 256833.5700 4.0381
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Number of Children (Unduplicated) With at Least One Service 1115
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Center 05
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 5725 60269.250000 182642.5900 182642.5900
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
3757 3332.250000 74125.8800 7119.6800
Other 6 1.750000 65.1000 0.0000
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Total 9488 63603.250000 256833.5700 189762.2700