CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2022 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 1722 1752.250000 65152.4000 37.1821
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 10 12.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2826 13731.75000 510188.9500 37.1540
Subtotal (Total Children Is Unduplicated) 2994 15496.50000 575341.3500 37.1272
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 5 6.000000 291.0000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 21 17.000000 850.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 24 43.500000 3162.5000 72.7011
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 28 52.000000 3900.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 13.000000 975.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 18.500000 1387.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 35 60.500000 3357.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 266 491.000000 36408.4000 74.1515
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 222 424.500000 31013.2600 73.0583
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 176 315.000000 23485.7500 74.5579
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 9.500000 670.5000 70.5789
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 668 1288.000000 71484.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 25 46.000000 2553.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 125 215.500000 16162.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.000000 600.0000 75.0000
NURS-T1001-NURSING ASSESSMENT 1 1.000000 50.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 6 6.000000 308.4600 51.4100
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 15 18.000000 897.9700 49.8872
PSTH-97162-PT EVAL MODERATE COMPLEXITY 8 8.000000 373.8700 46.7338
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 73 76.000000 3800.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 21 22.000000 1073.8800 48.8127
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 31 32.000000 1644.0400 51.3763
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.7200 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 4 10.000000 529.3000 52.9300
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 52.5700 52.5700
Subtotal (Total Children Is Unduplicated) 1224 3221.000000 207607.2300 64.4543
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 5.000000 631.9800 126.3960
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 458 619.000000 30925.0000 49.9596
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 343 377.000000 18850.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 7 6.750000 168.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 48 83.750000 4187.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 31 38.000000 1900.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 127 240.750000 12037.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 34 39.500000 1975.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 93 235.250000 11762.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 8 10.750000 537.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 178 504.250000 25212.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 56 115.250000 5762.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 111 259.000000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 77 111.750000 5587.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 336 2267.250000 113337.5000 49.9890
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 406 2797.000000 139850.0000 50.0000
INTR-T1013-INTERPRETER 18 131.000000 6382.5000 48.7214
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1047 12199.00000 121828.0000 9.9867
OCCT-97530-OT SESSION BY LICENSED OT 23 207.250000 14373.6800 69.3543
OCCT-97530GT-OT SESSION BY LICENSED OT 14 17.000000 1158.8300 68.1665
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 3.000000 214.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 61 631.250000 44416.8700 70.3634
PHY-97110GT-PT SESSION BY LICENSED PT 9 23.000000 1653.0000 71.8696
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.750000 53.5800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 135 958.000000 63578.0100 66.3654
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 32 45.000000 3236.1200 71.9138
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 142.8800 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 1.500000 55.5000 37.0000
TRAV-TRAVS-Travel by mile 999 225022.0000 100099.8800 0.4448
Subtotal (Total Children Is Unduplicated) 1348 246953.0000 730061.7800 2.9563
CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 2
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
-----------------------------------------------------------------------------------------------------------------------
Total 265670.500000 1513010.3600 5.6951
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Number of Children (Unduplicated) With at Least One Service 3046
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Center 03
Flag Claims Units Chgs Paid
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R 107 145.500000 5412.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 6184 4286.000000 165996.2400 0.0000
P 28899 198063.500000 708001.3500 707815.2800
D 82 83.250000 3621.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1135 6746.250000 33611.8900 33599.3900
T 0 0.000000 0.0000 0.0000
22059 56083.500000 586283.1300 0.0000
Other 266 262.500000 10084.1500 0.0000
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Total 58732 265670.500000 1513010.3600 741414.6700