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
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 478 473.000000 17595.6000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 8.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 514 1085.000000 40315.5000 37.1571
Subtotal (Total Children Is Unduplicated) 821 1566.250000 57911.1000 36.9744
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 10 6.500000 325.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 12.500000 937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 54 101.500000 7612.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 38.000000 2850.0000 75.0000
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 6 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 138.000000 7659.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.000000 675.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 6 6.000000 308.4600 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 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) 181 346.000000 22596.8900 65.3089
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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 14 14.000000 700.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 77 167.750000 8387.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 112 251.000000 12550.0000 50.0000
INTR-T1013-INTERPRETER 4 45.500000 2150.0000 47.2527
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 564 3249.000000 32408.0000 9.9748
OCCT-97530-OT SESSION BY LICENSED OT 8 32.000000 2302.7200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 23 88.000000 6278.5100 71.3467
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 150.000000 10688.6500 71.2577
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 9.500000 683.6200 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 0.750000 27.7500 37.0000
TRAV-TRAVS-Travel by mile 527 56670.00000 25212.0400 0.4449
Subtotal (Total Children Is Unduplicated) 651 61259.50000 129242.1700 2.1097
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Total 63171.750000 209750.1600 3.3203
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Number of Children (Unduplicated) With at Least One Service 1165
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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 1409 12759.250000 28051.3300 28051.3300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 740 5489.500000 13059.1700 13059.1700
T 0 0.000000 0.0000 0.0000
7693 44923.000000 168639.6600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9842 63171.750000 209750.1600 41110.5000