CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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 813 830.750000 30903.9000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1620 7170.000000 266724.0000 37.2000
Subtotal (Total Children Is Unduplicated) 1655 8000.750000 297627.9000 37.2000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 5 5.000000 250.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 7.000000 350.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 12 9.500000 475.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 21.500000 1612.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 17.000000 1275.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 29.000000 1609.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 248 313.000000 23475.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 17.000000 1275.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 335 591.500000 32828.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 231 370.000000 27750.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 98 98.000000 13386.8000 136.6000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.4700 31.4700
OCTH-97165-OT EVAL LOW COMPLEXITY 12 12.000000 540.3600 45.0300
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 14 14.000000 719.7400 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 9 9.000000 462.6900 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 11 11.000000 565.5100 51.4100
Subtotal (Total Children Is Unduplicated) 422 1527.500000 106733.2300 69.8745
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 30.750000 1537.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.500000 25.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 39 1419.000000 35575.0000 25.0705
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1064 10592.00000 529280.0000 49.9698
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 101 382.000000 19050.0000 49.8691
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1080 10591.00000 105852.0000 9.9945
OCCT-97530-OT SESSION BY LICENSED OT 35 148.500000 10513.6800 70.7992
OCCT-97530HM-OT SESSION BY OT ASST 15 90.500000 5212.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 32 145.000000 10027.2400 69.1534
PHY-97110HM-PT SESSION BY PT ASST 32 125.250000 7164.7600 57.2037
PHY-97110TL-PT SESSION BY LICENSED PT 1 8.000000 575.6800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 133.000000 9570.6800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 3.000000 215.8800 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.000000 115.2000 57.6000
Subtotal (Total Children Is Unduplicated) 1255 23674.50000 734915.4200 31.0425
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Total 33202.750000 1139276.5500 34.3127
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Number of Children (Unduplicated) With at Least One Service 1990
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Center 04
Flag Claims Units Chgs Paid
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R 210 326.500000 12902.5500 0.0000
U 0 0.000000 0.0000 0.0000
B 2014 3254.750000 126793.8000 0.0000
P 4218 14460.500000 289699.0500 287694.1500
D 213 339.500000 12946.4900 0.0000
S 3 4.250000 158.1000 0.0000
H 2281 8816.500000 442804.0000 230.0000
T 0 0.000000 0.0000 0.0000
3777 5758.250000 237245.3800 831.0800
Other 123 242.500000 16727.1800 676.4000
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Total 12839 33202.750000 1139276.5500 289431.6300