CMS/EIP Fiscal Report Center: 09
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 1980 6136.000000 228083.7500 37.1714
TCM-T1017TL-TARGETED CASE MANAGEMENT 2074 7595.500000 282534.0000 37.1976
Subtotal (Total Children Is Unduplicated) 2275 13731.50000 510617.7500 37.1859
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 228 405.250000 20262.5000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 18 26.500000 1987.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 11 19.000000 1425.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 22 33.000000 1831.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 328 597.000000 44775.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 263 466.000000 34950.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 114 214.000000 16050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 458 806.500000 44760.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 61 117.500000 8812.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 4 11.000000 550.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 17 55.000000 2750.0000 50.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 4 4.000000 205.6400 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 14 111.000000 5874.2600 52.9213
Subtotal (Total Children Is Unduplicated) 886 2896.750000 186261.1600 64.3000
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 87 154.500000 7675.0000 49.6764
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 21 31.000000 1550.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 110 137.750000 3443.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 15 15.000000 750.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 2 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 16.000000 800.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 15.000000 750.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 17 17.750000 887.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 4 3.000000 150.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 55 123.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 20.000000 1000.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1150 8161.000000 407714.2400 49.9589
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 103 337.000000 16850.0000 50.0000
INTR-T1013-INTERPRETER 137 558.750000 27937.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 421 2227.000000 22220.0000 9.9775
OCCT-97530-OT SESSION BY LICENSED OT 149 952.000000 68505.9200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 4 29.000000 2086.8400 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 4 20.000000 1439.2000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 159 1119.000000 80462.7300 71.9059
PHY-97110GT-PT SESSION BY LICENSED PT 6 45.000000 3238.2000 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 300 2396.750000 172470.1300 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 23 107.000000 7699.7200 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 21 76.000000 5468.9600 71.9600
TRAV-TRAVS-Travel by mile 1321 121204.0000 53229.1200 0.4392
Subtotal (Total Children Is Unduplicated) 1622 137772.2500 886622.7300 6.4354
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Total 154400.500000 1583501.6400 10.2558
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Number of Children (Unduplicated) With at Least One Service 2391
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Center 09
Flag Claims Units Chgs Paid
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R 196 195.750000 7548.9400 0.0000
U 0 0.000000 0.0000 0.0000
B 4271 4552.000000 186160.9300 0.0000
P 12618 112142.250000 718349.1100 718349.1100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 360 462.500000 25951.0500 0.0000
T 4714 30041.250000 256300.1500 256300.1500
2140 6571.750000 358592.8600 0.0000
Other 224 435.000000 30598.6000 0.0000
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Total 24523 154400.500000 1583501.6400 974649.2600