CMS/EIP Fiscal Report Center: 53
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 1139 1873.500000 69526.8000 37.1106
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 46 44.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 483 852.750000 31713.0000 37.1891
Subtotal (Total Children Is Unduplicated) 1238 2771.000000 101239.8000 36.5355
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 5.500000 275.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 21 39.000000 2925.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 35 63.500000 3524.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.000000 675.0000 75.0000
Subtotal (Total Children Is Unduplicated) 54 154.000000 10025.2500 65.0990
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 71.9600 71.9600
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 19.000000 950.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 23 19.750000 987.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.250000 6.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 17 13.500000 675.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 161 133.500000 6662.5000 49.9064
CONIP-CONIP-CONSULT, ITDS PHONE 3 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 45 53.250000 2662.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 81 63.750000 3187.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.250000 6.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 34 50.000000 2500.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 118 66.500000 3325.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 26 23.750000 1187.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 173 116.750000 5837.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 6 3.250000 81.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 380 1242.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 45 216.250000 10812.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 15 43.000000 2150.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 611 2713.000000 27130.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 45.500000 3274.1800 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 2 3.000000 215.8800 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 7.000000 503.7200 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 3 5.000000 359.8000 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.500000 35.9800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 14.000000 1007.4400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 7 7.000000 503.7200 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 4 12.000000 863.5200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 287.8400 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 39 40.250000 1489.2500 37.0000
TRAV-TRAVS-Travel by mile 288 18994.00000 8450.0100 0.4449
Subtotal (Total Children Is Unduplicated) 669 23915.75000 85418.4700 3.5716
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Total 26840.750000 196683.5200 7.3278
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Number of Children (Unduplicated) With at Least One Service 1420
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Center 53
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 0 0.000000 0.0000 0.0000
D 201 137.000000 6204.1400 0.0000
S 77 60.000000 1533.8000 0.0000
H 0 0.000000 0.0000 0.0000
T 1313 11565.500000 17344.1500 17344.1500
10184 15059.000000 170716.4300 0.0000
Other 20 19.250000 885.0000 0.0000
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Total 11795 26840.750000 196683.5200 17344.1500