CMS/EIP Fiscal Report Center: 03
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 478 473.000000 17595.6000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 8.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1157 2627.500000 97696.5000 37.1823
Subtotal (Total Children Is Unduplicated) 1270 3108.750000 115292.1000 37.0863
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 12 8.500000 425.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 16.000000 1200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 10.000000 750.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 19.500000 1082.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 89 164.500000 12156.6700 73.9007
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 51 96.500000 6960.2200 72.1266
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 53.500000 4002.5000 74.8131
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 193 362.500000 20118.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 30.000000 2250.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 7 7.000000 359.8700 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 308.4600 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 52.9300 52.9300
Subtotal (Total Children Is Unduplicated) 338 799.500000 51147.4000 63.9742
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 140 154.750000 7737.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 80 73.750000 3687.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 14 16.000000 800.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 2 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 50 71.750000 3587.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 14 14.000000 700.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 30 42.000000 2100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 102 169.750000 8487.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 7 8.000000 400.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 21 25.500000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 22 22.000000 1100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 129 345.250000 17262.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 221 948.000000 47400.0000 50.0000
INTR-T1013-INTERPRETER 4 45.500000 2150.0000 47.2527
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 564 3250.000000 32418.0000 9.9748
OCCT-97530-OT SESSION BY LICENSED OT 8 37.000000 2662.5200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 5 5.000000 359.8000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 24 94.000000 6710.2700 71.3859
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 62 246.000000 16618.8900 67.5565
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 11 13.250000 953.4700 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 0.750000 27.7500 37.0000
TRAV-TRAVS-Travel by mile 527 56706.00000 25228.0600 0.4449
Subtotal (Total Children Is Unduplicated) 675 62292.75000 180600.7200 2.8992
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Total 66201.000000 347040.2200 5.2422
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Number of Children (Unduplicated) With at Least One Service 1415
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Center 03
Flag Claims Units Chgs Paid
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R 4 3.000000 111.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 217 133.750000 5157.2000 0.0000
P 1784 13163.250000 46623.8000 46624.6400
D 1 0.500000 18.6000 0.0000
S 0 0.000000 0.0000 0.0000
H 914 5676.000000 22874.7700 22874.7700
T 0 0.000000 0.0000 0.0000
10275 47177.250000 270395.9000 0.0000
Other 43 47.250000 1858.3500 0.0000
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Total 13238 66201.000000 347040.2200 69499.4100