CMS/EIP Fiscal Report Center: 55
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 1237 1266.250000 47104.4000 37.1999
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 111 143.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1355 5548.500000 206404.2000 37.2000
Subtotal (Total Children Is Unduplicated) 1456 6958.000000 253508.6000 36.4341
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 19 39.000000 1950.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 5.000000 250.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 7 14.000000 700.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 17 36.000000 2700.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 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 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 345 687.999996 51600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 26 51.999999 3900.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 52.000000 3900.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 57 113.000000 8475.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 193 386.000000 21423.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 42.000000 2331.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 18 18.000000 925.3800 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 3.000000 154.2300 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 5.000000 257.0500 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 30 33.000000 1696.5300 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 7.000000 359.8700 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92521TL-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92521TLGT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 18 19.069830 980.3800 51.4100
Subtotal (Total Children Is Unduplicated) 493 1572.069825 105702.3600 67.2377
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 368.2600 368.2600
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 13 13.000000 650.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 43 45.500000 2275.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 9 9.000000 450.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 28 37.000000 925.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 32.500000 1625.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 27 74.000000 1850.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 37 39.000000 1950.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 9 9.000000 450.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 24 29.000000 725.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 12.000000 600.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 275 1820.000000 91000.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 19 88.500000 4425.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 549 4466.000000 44660.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 99 496.500000 35728.1400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 6.000000 431.7600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 126 1037.000001 59731.2000 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 6.000000 345.6000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 1 18.000000 1036.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 66 475.999998 34252.9600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 2 3.000000 215.8800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 62 372.000000 21412.3200 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 6.000000 345.3600 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 1 7.000000 503.7200 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 1 7.000000 402.9200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 164 940.500000 67678.3800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 9.500000 683.6200 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 9 60.000000 4317.6000 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 2.500000 179.9000 71.9600
TRAV-TRAVS-Travel by mile 50 1866.000000 830.0600 0.4448
Subtotal (Total Children Is Unduplicated) 649 11989.50000 380099.4800 31.7027
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Total 20519.569824 739310.4400 36.0295
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Number of Children (Unduplicated) With at Least One Service 1495
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Center 55
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 2729 2819.750000 125792.6500 0.0000
P 6497 7622.205680 176440.8100 176440.8100
D 0 0.000000 0.0000 0.0000
S 2 3.273600 245.5200 0.0000
H 92 155.000000 11411.0700 0.0000
T 0 0.000000 0.0000 0.0000
11237 9919.340544 425420.3900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 20557 20519.569824 739310.4400 176440.8100