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
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 787 800.750000 29787.9000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 201 240.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 193 302.000000 11234.4000 37.2000
Subtotal (Total Children Is Unduplicated) 840 1343.250000 41022.3000 30.5396
-----------------------------------------------------------------------------------------------------------------------
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 2 4.000000 300.0000 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 38.000000 2850.0000 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 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 51.000000 2830.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 27.000000 2025.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 70 180.000000 11811.9100 65.6217
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
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 96 680.750000 34037.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 25 81.750000 4087.5000 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 3 11.500000 827.5400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 5.000000 359.8000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 4 18.250000 1313.2700 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 27.500000 1978.9000 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) 513 25005.50000 99898.1700 3.9950
-----------------------------------------------------------------------------------------------------------------------
Total 26528.750000 152732.3800 5.7572
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 981
-----------------------------------------------------------------------------------------------------------------------
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3174 13120.500000 72853.2300 72864.4110
1006 3037.500000 21501.4300 0.0000
Other 3058 10370.750000 58377.7200 0.0000
---------------------------------------------------------
Total 7238 26528.750000 152732.3800 72864.4110