CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 870 778.250000 28932.3000 37.1761
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 212 244.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 187 380.000000 14136.0000 37.2000
Subtotal (Total Children Is Unduplicated) 906 1403.000000 43068.3000 30.6973
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 10 9.250000 462.5000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 33.500000 2512.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 56.000000 3108.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 26.500000 1987.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 23.500000 1762.5000 75.0000
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 69 177.250000 11683.6600 65.9163
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 20.500000 1025.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 11 12.250000 612.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 3.000000 75.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 73 76.000000 3800.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 51 39.000000 1910.0000 48.9744
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 35 35.500000 1775.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 17 9.250000 462.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 22 22.000000 1100.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 40 22.750000 1137.5000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 9.000000 450.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 86 601.250000 30062.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 22 81.250000 4062.5000 50.0000
INTR-T1013-INTERPRETER 32 140.250000 6987.5000 49.8217
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 321 2307.000000 23070.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 10.000000 719.6000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 3 7.000000 503.7200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 1.500000 107.9400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 7.250000 521.7100 71.9600
TRAV-TRAVS-Travel by mile 265 21908.00000 9736.2100 0.4444
Subtotal (Total Children Is Unduplicated) 490 25314.25000 88156.6800 3.4825
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Total 26894.500000 142908.6400 5.3137
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Number of Children (Unduplicated) With at Least One Service 1016
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Center 02
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 0 0.000000 0.0000 0.0000
S 1 1.000000 10.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3007 13128.500000 66828.1700 66958.4260
763 1626.250000 14442.7600 0.0000
Other 3410 12138.750000 61627.7100 0.0000
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Total 7181 26894.500000 142908.6400 66958.4260