CMS/EIP Fiscal Report Center: 53
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 1227 2077.750000 77022.4500 37.0701
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 17 13.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 582 968.250000 35907.2500 37.0847
Subtotal (Total Children Is Unduplicated) 1332 3059.500000 112929.7000 36.9112
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 3.000000 145.5000 48.5000
BEHV-BEHV-BEHAVIORAL ASSESSMENT 1 2.000000 250.0000 125.0000
EXIT-EXIT-EXIT ASSESSMENT 4 8.000000 400.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 11.000000 825.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 36.000000 2700.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 11.500000 862.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 28 48.000000 2664.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
Subtotal (Total Children Is Unduplicated) 48 130.500000 8642.7500 66.2280
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 8.000000 617.4400 77.1800
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 4.500000 225.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 23 20.000000 1000.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 16 14.750000 737.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 147 121.250000 6062.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.250000 6.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 41 56.500000 2825.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 78 53.000000 2600.0000 49.0566
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 29 35.750000 1787.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 166 98.750000 4925.0000 49.8734
CONPP-CONPP-CONSULT, PT, PHONE 3 1.250000 31.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 30 29.250000 1462.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 137 86.000000 4300.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 7 2.750000 68.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 386 1183.000000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 55 212.500000 10625.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 28 48.750000 2437.5000 50.0000
INTR-T1013-INTERPRETER 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 654 3161.000000 31610.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 17.000000 1223.3200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 4 4.500000 323.8200 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 2.500000 179.9000 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 2 3.000000 215.8800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 19.000000 1367.2400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 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 3 4.000000 287.8400 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 40 63.000000 2331.0000 37.0000
TRAV-TRAVS-Travel by mile 304 18287.00000 8134.9500 0.4448
Subtotal (Total Children Is Unduplicated) 714 23545.25000 85869.9400 3.6470
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Total 26735.250000 207442.3900 7.7591
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Number of Children (Unduplicated) With at Least One Service 1532
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Center 53
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 0 0.000000 0.0000 0.0000
D 270 178.250000 7564.0200 0.0000
S 8 7.000000 40.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1496 10682.750000 18396.7500 18396.7500
11377 15848.250000 180734.8200 0.0000
Other 24 19.000000 706.8000 0.0000
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Total 13175 26735.250000 207442.3900 18396.7500