CMS/EIP Fiscal Report Center: 03
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 493 457.250000 17009.7000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 456 1140.750000 42435.9000 37.2000
Subtotal (Total Children Is Unduplicated) 799 1599.750000 59445.6000 37.1593
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 2 1.750000 87.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 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 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 44.000000 3300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 32.000000 2400.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 87 181.000000 10045.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 29.500000 2212.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
NURS-T1001-NURSING ASSESSMENT 1 1.000000 50.0000 50.0000
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 16 16.000000 800.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 52.9300 52.9300
Subtotal (Total Children Is Unduplicated) 156 353.250000 22192.8700 62.8248
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 133 147.250000 7362.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 49 47.750000 2387.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 3.250000 81.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 21 33.750000 1687.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 9 10.750000 537.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 57 69.750000 3487.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 4 5.000000 250.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 45 60.750000 3037.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 80 119.750000 5987.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 10 12.000000 600.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 23 58.000000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 72 153.500000 7675.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 26 31.000000 1550.0000 50.0000
INTR-T1013-INTERPRETER 6 28.750000 1437.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 540 2653.000000 26530.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 40.000000 2878.4000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 3 3.000000 215.8800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 14 58.750000 4227.6500 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 113.000000 8131.4800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 6.000000 431.7600 71.9600
TRAV-TRAVS-Travel by mile 521 47896.00000 21303.3100 0.4448
Subtotal (Total Children Is Unduplicated) 626 51556.00000 100071.6900 1.9410
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Total 53509.000000 181710.1600 3.3959
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Number of Children (Unduplicated) With at Least One Service 1122
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Center 03
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 56 392.500000 1888.2100 1888.2100
D 0 0.000000 0.0000 0.0000
S 11 124.000000 507.8100 507.8100
H 29 250.000000 483.2200 483.2200
T 0 0.000000 0.0000 0.0000
8611 52740.500000 178743.7200 0.0000
Other 2 2.000000 87.2000 0.0000
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Total 8709 53509.000000 181710.1600 2879.2400