CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 Page: 1
List order: No List
Payclass Filters:OTHER
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 1 3.750000 139.5000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 151 283.500000 10546.2000 37.2000
Subtotal (Total Children Is Unduplicated) 151 287.250000 10685.7000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 3 6.000000 300.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 10.500000 787.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 7.000000 525.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 17.500000 971.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 63 79.500000 5962.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 56 73.500000 5512.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 18 32.500000 2437.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 120 154.500000 8574.7500 55.5000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 11 34.000000 1700.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 264.6500 52.9300
Subtotal (Total Children Is Unduplicated) 168 426.000000 27338.4700 64.1748
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 8 12.000000 600.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 1 2.000000 100.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 13 13.000000 325.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 1.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 29.000000 1450.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 263 1313.000000 65208.2300 49.6635
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 54 272.000000 19573.1200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 48 326.000000 23458.9600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 2 7.000000 503.7200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 118 521.000000 37419.2000 71.8219
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 33.000000 2374.6800 71.9600
TRAV-TRAVS-Travel by mile 466 25330.00000 11224.2900 0.4431
Subtotal (Total Children Is Unduplicated) 606 27868.75000 162706.1200 5.8383
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Total 28582.000000 200730.2900 7.0230
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Number of Children (Unduplicated) With at Least One Service 773
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Center 09
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 1036 19624.500000 118631.2100 118631.2100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 396 511.500000 28592.8500 0.0000
T 0 0.000000 0.0000 0.0000
493 8446.000000 53506.2300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1925 28582.000000 200730.2900 118631.2100