CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 1039 595.000000 22134.0000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 2.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1983 6388.250000 237576.7000 37.1896
Subtotal (Total Children Is Unduplicated) 2014 6985.750000 259710.7000 37.1772
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 2 4.000000 150.0000 37.5000
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 6 10.500000 787.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 10.000000 750.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 15.500000 860.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 38.000000 2850.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 206 355.000000 26625.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 22.500000 1687.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 197 344.500000 25837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 97 174.000000 13050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 36.500000 2025.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 301 549.000000 30469.5000 55.5000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 142.2300 142.2300
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 454 1587.000000 107018.6000 67.4345
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 99 83.000000 3962.5000 47.7410
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 23 19.000000 950.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 104 82.000000 2037.5000 24.8476
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 12 14.500000 725.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 10 11.500000 550.0000 47.8261
CONIP-CONIP-CONSULT, ITDS PHONE 16 16.500000 400.0000 24.2424
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 6.000000 300.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 7 12.500000 600.0000 48.0000
CONOP-CONOP-CONSULT, OT, PHONE 8 8.500000 212.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 5.500000 231.2500 42.0455
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 3 3.500000 175.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 4.000000 100.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 3.500000 125.0000 35.7143
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 4.500000 112.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 9.000000 450.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1039 6508.750000 325137.5000 49.9539
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 135 447.250000 22317.5000 49.8994
INTR-T1013-INTERPRETER 1 20.500000 1556.0100 75.9029
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1094 7206.000000 71610.0000 9.9376
OCCT-97530-OT SESSION BY LICENSED OT 32 124.250000 8392.7200 67.5470
OCCT-97530GT-OT SESSION BY LICENSED OT 14 23.500000 1651.0600 70.2579
OCCT-97530HM-OT SESSION BY OT ASST 19 68.500000 4088.3000 59.6832
OCCT-97530HMGT-OT SESSION BY OT ASST 4 10.000000 575.1000 57.5100
PHY-97110-PT SESSION BY LICENSED PT 37 141.750000 9915.6800 69.9519
PHY-97110GT-PT SESSION BY LICENSED PT 14 39.500000 2741.5700 69.4068
PHY-97110HM-PT SESSION BY PT ASST 22 67.750000 3881.0400 57.2847
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 13 27.750000 1608.0900 57.9492
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 77 359.000000 24972.8600 69.5623
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 43 157.250000 10241.2300 65.1271
TRAV-TRAVS-Travel by mile 459 20767.00000 9244.8700 0.4452
Subtotal (Total Children Is Unduplicated) 1264 36254.25000 508932.9100 14.0379
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Total 44827.000000 875662.2100 19.5343
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Number of Children (Unduplicated) With at Least One Service 2103
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Center 06
Flag Claims Units Chgs Paid
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R 1 0.500000 18.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 8003 7851.750000 173932.6000 173932.6000
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
21144 36797.750000 694235.3900 0.0000
Other 270 177.000000 7475.6200 0.0000
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Total 29418 44827.000000 875662.2100 173932.6000