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
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 813 830.750000 30903.9000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 483 2187.750000 81384.3000 37.2000
Subtotal (Total Children Is Unduplicated) 1052 3018.500000 112288.2000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 5 5.000000 250.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 6.500000 325.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 12 9.500000 475.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 78 105.000000 7875.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 102 149.500000 8297.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 62.000000 4650.0000 75.0000
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 154.2300 51.4100
Subtotal (Total Children Is Unduplicated) 137 368.500000 23919.2100 64.9097
-----------------------------------------------------------------------------------------------------------------------
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
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 242 2276.000000 113750.0000 49.9780
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 25 97.000000 4800.0000 49.4845
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1080 10591.00000 105852.0000 9.9945
OCCT-97530-OT SESSION BY LICENSED OT 4 19.000000 1367.2400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 2 12.000000 691.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 7 27.500000 1978.9000 71.9600
PHY-97110HM-PT SESSION BY PT ASST 5 32.000000 1841.9200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 36.000000 2590.5600 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.000000 115.2000 57.6000
Subtotal (Total Children Is Unduplicated) 1120 13127.75000 234749.5200 17.8819
-----------------------------------------------------------------------------------------------------------------------
Total 16514.750000 370956.9300 22.4622
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1693
-----------------------------------------------------------------------------------------------------------------------
Center 04
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 3414 13112.750000 234392.9800 234396.7800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 19.000000 620.2400 230.0000
T 0 0.000000 0.0000 0.0000
2914 3382.000000 135871.7500 0.0000
Other 1 1.000000 71.9600 71.9600
---------------------------------------------------------
Total 6335 16514.750000 370956.9300 234698.7400