CMS/EIP Fiscal Report Center: 02
Services beginning 07/01/2022 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 1946 3113.750000 115673.5000 37.1493
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 685 890.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 495 1416.000000 52602.7500 37.1488
Subtotal (Total Children Is Unduplicated) 2021 5419.750000 168276.2500 31.0487
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 48 56.250000 2812.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 118.000000 8850.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 37 71.500000 5362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 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 129 241.500000 13347.7500 55.2702
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 35 64.500000 3579.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 112.000000 8400.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 64.000000 4800.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 11.1600 11.1600
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 287 792.250000 51381.9900 64.8558
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 3049.9900 1524.9950
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 87 109.000000 5450.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 51 73.750000 3687.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 5 4.750000 118.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 213 328.000000 16375.2500 49.9245
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 113 107.500000 5335.0000 49.6279
CONIP-CONIP-CONSULT, ITDS PHONE 3 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 81 96.250000 4812.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 78 79.250000 3962.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 6.000000 300.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 4 3.000000 150.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 2.250000 56.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 99 101.750000 5087.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 101 79.750000 3987.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 19 62.500000 3125.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 160 2332.500000 116625.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 44 296.250000 14812.5000 50.0000
INTR-T1013-INTERPRETER 59 385.000000 19225.0000 49.9351
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 583 9059.000000 90714.0000 10.0137
OCCT-97530-OT SESSION BY LICENSED OT 7 41.000000 2946.4600 71.8649
OCCT-97530GT-OT SESSION BY LICENSED OT 5 33.750000 2428.6500 71.9600
PHY-97110-PT SESSION BY LICENSED PT 10 34.250000 2275.4300 66.4359
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 58.750000 4225.0500 71.9157
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 9 6.000000 222.0000 37.0000
TRAV-TRAVS-Travel by mile 687 82258.00000 36567.5100 0.4445
Subtotal (Total Children Is Unduplicated) 987 95564.25000 345639.3400 3.6168
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Total 101776.250000 565297.5800 5.5543
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Number of Children (Unduplicated) With at Least One Service 2063
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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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 13896 61333.750000 305931.5300 305780.9870
1015 3046.500000 21591.4300 0.0000
Other 12788 37396.000000 237774.6200 0.0000
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Total 27699 101776.250000 565297.5800 305780.9870