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
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 1722 1752.250000 65152.4000 37.1821
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 10 12.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1464 6250.000000 232187.0000 37.1499
Subtotal (Total Children Is Unduplicated) 2407 8014.750000 297339.4000 37.0990
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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 19 15.000000 750.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 34.500000 2587.5000 75.0000
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 21 39.500000 2962.5000 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 6 10.000000 750.0000 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 6 10.000000 750.0000 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 20 36.000000 1998.0000 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 181 335.500000 25162.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 114 217.500000 16262.5000 74.7701
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 68 122.500000 9158.2500 74.7612
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 357 691.000000 38350.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 32.000000 1776.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 99.000000 7425.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
NURS-T1001-NURSING ASSESSMENT 1 1.000000 50.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 205.6400 51.4100
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 5 6.000000 281.0500 46.8417
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 51 52.000000 2600.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 13 13.000000 668.3300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 616.5600 51.3800
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.7200 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 3 7.000000 370.5100 52.9300
Subtotal (Total Children Is Unduplicated) 774 1790.500000 116215.4100 64.9067
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 4.000000 331.9900 82.9975
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 456 616.500000 30800.0000 49.9594
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 45 63.750000 3187.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 274 1712.250000 85612.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 237 694.250000 34712.5000 50.0000
INTR-T1013-INTERPRETER 18 131.000000 6382.5000 48.7214
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1047 12196.00000 121798.0000 9.9867
OCCT-97530-OT SESSION BY LICENSED OT 16 133.500000 9601.7200 71.9230
OCCT-97530GT-OT SESSION BY LICENSED OT 7 10.000000 719.0800 71.9080
PHY-97110-PT SESSION BY LICENSED PT 41 316.750000 22664.7400 71.5540
PHY-97110GT-PT SESSION BY LICENSED PT 7 7.250000 521.1900 71.8883
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 88 477.750000 34262.6200 71.7166
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 18 24.000000 1726.5200 71.9383
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 1.500000 55.5000 37.0000
TRAV-TRAVS-Travel by mile 999 224986.0000 100083.8600 0.4448
Subtotal (Total Children Is Unduplicated) 1302 243284.7500 534853.9700 2.1985
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Total 253090.000000 948408.7800 3.7473
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Number of Children (Unduplicated) With at Least One Service 2735
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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 23209 193038.250000 461303.6800 461303.6800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 890 6465.000000 18533.8100 18521.3100
T 0 0.000000 0.0000 0.0000
19288 53583.250000 468400.8400 0.0000
Other 3 3.500000 170.4500 0.0000
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Total 43390 253090.000000 948408.7800 479824.9900