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
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 412 179.750000 6677.4000 37.1483
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 35 17.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 354 938.500000 34763.4000 37.0414
Subtotal (Total Children Is Unduplicated) 635 1135.750000 41440.8000 36.4876
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 620.0000 62.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 250.0000 62.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 10 27.000000 1577.8200 58.4378
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 61 63.250000 3162.5000 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 147 225.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 42.500000 2125.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 542 3120.000000 31200.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 1 0.750000 53.9700 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 15.000000 1079.4000 71.9600
TRAV-TRAVS-Travel by mile 437 28053.00000 12481.3400 0.4449
Subtotal (Total Children Is Unduplicated) 701 31878.75000 67622.4800 2.1212
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Total 33041.500000 110641.1000 3.3485
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Number of Children (Unduplicated) With at Least One Service 969
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Center 52
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 1 0.250000 9.3000 9.3000
D 17 19.500000 1008.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3182 31597.250000 65042.3900 63789.3500
2342 1422.500000 44481.4100 0.0000
Other 1 2.000000 100.0000 100.0000
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Total 5543 33041.500000 110641.1000 63898.6500