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
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 1237 1266.250000 47104.4000 37.1999
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 111 143.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 864 2593.750000 96487.5000 37.2000
Subtotal (Total Children Is Unduplicated) 1381 4003.250000 143591.9000 35.8688
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 17 34.000000 1700.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 6 12.000000 600.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 51 95.742131 7180.6600 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.770133 282.7600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 23.615466 1771.1600 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 102.000000 5661.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 20.000000 1110.0000 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 4 4.000000 205.6400 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 0.858588 44.1400 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 308.4600 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 0.805485 41.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 2.309473 118.7300 51.4100
Subtotal (Total Children Is Unduplicated) 141 351.101276 22287.7800 63.4796
-----------------------------------------------------------------------------------------------------------------------
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 93 580.500000 29025.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 6 23.000000 1150.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 549 4463.000000 44630.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 118.668844 8539.4100 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 26 160.340279 9235.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 23 128.388272 9238.8200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 18 73.921995 4254.9500 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 184.291551 13261.6200 71.9600
TRAV-TRAVS-Travel by mile 50 1866.000000 830.0600 0.4448
Subtotal (Total Children Is Unduplicated) 596 7902.110941 132227.6400 16.7332
-----------------------------------------------------------------------------------------------------------------------
Total 12256.462217 298107.3200 24.3225
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1458
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 5176 6283.705680 112812.5100 112812.5100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7395 5972.756537 185294.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12571 12256.462217 298107.3200 112812.5100