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
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 1980 6136.000000 228083.7500 37.1714
TCM-T1017TL-TARGETED CASE MANAGEMENT 888 3292.250000 122471.7000 37.2000
Subtotal (Total Children Is Unduplicated) 2096 9428.250000 350555.4500 37.1814
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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 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 76 148.500000 11137.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 55 104.500000 7837.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 49 93.000000 6975.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 80 153.500000 8519.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 38.500000 2887.5000 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-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 3.000000 158.7900 52.9300
Subtotal (Total Children Is Unduplicated) 424 1039.250000 62946.0900 60.5688
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 64 110.500000 5475.0000 49.5475
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 19 29.000000 1450.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 89 107.750000 2693.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 10 10.000000 500.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 2 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 13 13.000000 650.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 10.000000 500.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 12 12.750000 637.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 4 3.000000 150.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 54 120.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 17.000000 850.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 369 1704.000000 85100.0000 49.9413
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 24 77.000000 3850.0000 50.0000
INTR-T1013-INTERPRETER 137 558.750000 27937.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 357 1519.000000 15140.0000 9.9671
OCCT-97530-OT SESSION BY LICENSED OT 38 150.000000 10794.0000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 3 16.000000 1151.3600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 26 132.750000 9552.6900 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 68 296.500000 21336.1400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 58.000000 4173.6800 71.9600
TRAV-TRAVS-Travel by mile 1239 92551.00000 40605.2700 0.4387
Subtotal (Total Children Is Unduplicated) 1417 97499.75000 232671.8900 2.3864
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Total 107967.250000 646173.4300 5.9849
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Number of Children (Unduplicated) With at Least One Service 2269
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Center 09
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 0 0.000000 0.0000 0.0000
P 11399 100245.000000 497403.3300 497403.3300
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 3445 7578.250000 140777.1400 140777.1400
76 80.000000 3217.9600 0.0000
Other 33 64.000000 4775.0000 0.0000
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Total 14953 107967.250000 646173.4300 638180.4700