CMS/EIP Fiscal Report Center: 52
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 412 179.750000 6677.4000 37.1483
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 35 17.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 880 2327.000000 86341.2000 37.1041
Subtotal (Total Children Is Unduplicated) 960 2524.250000 93018.6000 36.8500
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 39.000000 2925.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 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 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 18 36.000000 1998.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 210 442.000000 32000.0000 72.3982
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 96 194.000000 14400.0000 74.2268
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 44.000000 3140.0000 71.3636
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 231 460.500000 25557.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163TLGT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 41 41.000000 2050.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 8 20.000000 516.3300 25.8165
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 7 29.000000 1534.9700 52.9300
Subtotal (Total Children Is Unduplicated) 348 1357.500000 87669.1500 64.5813
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 62 64.500000 3225.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 50 55.750000 2787.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 23 17.750000 443.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 70 125.500000 6275.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 26 35.250000 1762.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 21 78.000000 3900.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 38 40.250000 2012.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 147 226.250000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 443 2192.000000 109435.0000 49.9247
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 5 4.750000 237.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 542 3124.000000 31230.0000 9.9968
OCCT-97530-OT SESSION BY LICENSED OT 16 49.500000 3562.0200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 10 33.000000 1900.8000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 17 76.500000 5504.9400 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TLHM-OT SESSION BY OT ASST 9 39.000000 2246.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 30 84.500000 6080.6200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 14 91.750000 5223.5700 56.9326
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 3 2.000000 115.1200 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 25 82.000000 5900.7200 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 8 38.750000 2230.4500 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 77 369.250000 25317.5900 68.5649
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 59 257.250000 18421.7100 71.6101
TRAV-TRAVS-Travel by mile 437 28072.00000 12486.6800 0.4448
Subtotal (Total Children Is Unduplicated) 703 35167.00000 250680.7900 7.1283
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Total 39048.750000 431368.5400 11.0469
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Number of Children (Unduplicated) With at Least One Service 1102
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Center 52
Flag Claims Units Chgs Paid
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R 19 20.000000 883.0400 0.0000
U 0 0.000000 0.0000 0.0000
B 875 908.250000 46050.9400 0.0000
P 1685 1789.250000 83698.0000 82245.9800
D 279 307.000000 16651.0000 515.0000
S 160 135.750000 6467.1200 782.3000
H 240 299.000000 17836.3000 0.0000
T 3852 32505.750000 117801.8100 109132.4900
3227 3081.750000 141880.3300 195.3400
Other 1 2.000000 100.0000 100.0000
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Total 10338 39048.750000 431368.5400 192971.1100