CMS/EIP Fiscal Report Center: 02
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 787 800.750000 29787.9000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 201 240.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 797 1196.000000 44472.6000 37.1844
Subtotal (Total Children Is Unduplicated) 983 2237.250000 74260.5000 33.1928
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 16 19.000000 950.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 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 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 78.000000 5850.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.500000 862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 87 168.500000 9351.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 16.000000 888.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 62.500000 4687.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 27.000000 2025.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 37.1500 37.1500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 74.3800 37.1900
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 219.6900 43.9380
Subtotal (Total Children Is Unduplicated) 171 433.000000 27709.8000 63.9949
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 5515.6000 1378.9000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 37.750000 1887.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 9 16.000000 800.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.750000 43.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 86 114.000000 5700.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 47 35.500000 1775.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 21 20.000000 1000.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 43 39.500000 1975.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 3 1.500000 75.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 43 41.250000 2062.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 29 20.500000 1025.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 12 53.500000 2675.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 123 766.000000 38300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 38 124.750000 6237.5000 50.0000
INTR-T1013-INTERPRETER 15 72.750000 3637.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 350 2498.000000 25104.0000 10.0496
OCCT-97530-OT SESSION BY LICENSED OT 29 157.500000 10428.0800 66.2100
OCCT-97530GT-OT SESSION BY LICENSED OT 5 29.250000 2104.8300 71.9600
PHY-97110-PT SESSION BY LICENSED PT 25 135.750000 8859.4800 65.2632
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.250000 161.9100 71.9600
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 210.000000 14857.4200 70.7496
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 2 1.250000 46.2500 37.0000
TRAV-TRAVS-Travel by mile 258 21226.00000 9424.6600 0.4440
Subtotal (Total Children Is Unduplicated) 533 25612.25000 143848.5700 5.6164
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Total 28282.500000 245818.8700 8.6916
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Number of Children (Unduplicated) With at Least One Service 1103
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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 3 3.000000 99.4600 -116.4200
H 0 0.000000 0.0000 0.0000
T 3756 13536.750000 105963.5200 106653.0870
1145 3145.250000 28440.2200 0.0000
Other 4800 11597.500000 111315.6700 0.0000
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Total 9704 28282.500000 245818.8700 106536.6670