CMS/EIP Fiscal Report Center: 04
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 2625 3450.000000 128199.9000 37.1594
TCM-T1017TL-TARGETED CASE MANAGEMENT 3677 29031.00000 1078399.9000 37.1465
Subtotal (Total Children Is Unduplicated) 3716 32481.00000 1206599.8000 37.1479
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 64 69.500000 3475.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 7.000000 350.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 63 51.000000 2550.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 29.500000 2212.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 17 19.000000 1425.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 19 23.000000 1725.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 19 25.500000 1902.7500 74.6176
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 23 30.500000 2258.2500 74.0410
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 45.500000 2525.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 43 63.000000 3496.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 402 486.000000 36430.5000 74.9599
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 381 423.000000 31725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 101 111.500000 8362.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 334 369.500000 27712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 668 1097.500000 60911.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 879 1390.500000 77172.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 582 851.000000 63825.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 324 455.000000 34066.5000 74.8714
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 382 383.000000 50829.8200 132.7149
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 7 7.000000 543.0500 77.5786
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 61 73.000000 3616.9800 49.5477
OCTH-97165TL-OT EVAL LOW COMPLEXITY 4 4.000000 205.6400 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 17.000000 873.6100 51.3888
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 5.000000 257.0500 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 35 42.000000 2078.5400 49.4890
PSTH-97161TL-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.8700 51.2900
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 23 31.000000 1593.3500 51.3984
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 6.000000 308.4600 51.4100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 49 64.000000 3287.7200 51.3706
SPCH-92521GT-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
SPCH-92521TL-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 8.000000 410.9200 51.3650
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 2.000000 96.2700 48.1350
Subtotal (Total Children Is Unduplicated) 1778 6211.500000 427475.9100 68.8201
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 60 172.750000 8637.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 1 1.000000 50.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 75 2324.000000 58200.0000 25.0430
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 16 65.000000 3250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1872 38100.50000 1903805.0000 49.9680
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 398 2358.000000 117800.0000 49.9576
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1916 39570.00000 395462.0000 9.9940
OCCT-97530-OT SESSION BY LICENSED OT 76 927.000000 65342.4600 70.4881
OCCT-97530HM-OT SESSION BY OT ASST 37 384.500000 22132.8000 57.5625
OCCT-97530TL-OT SESSION BY LICENSED OT 4 7.500000 539.7000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 54 612.500000 42199.2500 68.8967
PHY-97110HM-PT SESSION BY PT ASST 70 557.250000 31970.5300 57.3720
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.500000 85.7400 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 5 33.000000 2374.6800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 80 776.250000 55185.0600 71.0919
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 3.000000 215.8800 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 4.000000 229.6000 57.4000
SPL-92508HA-GROUP SPL SESSION PER CHILD 1 0.500000 6.9400 13.8800
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 2 3.000000 111.0000 37.0000
Subtotal (Total Children Is Unduplicated) 2203 85902.25000 2707648.1400 31.5201
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Total 124594.750000 4341723.8500 34.8468
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Number of Children (Unduplicated) With at Least One Service 3759
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Center 04
Flag Claims Units Chgs Paid
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R 210 326.500000 12902.5500 0.0000
U 0 0.000000 0.0000 0.0000
B 5979 8979.250000 357491.8000 0.0000
P 20676 60476.250000 1365302.3300 1339451.5800
D 988 1424.750000 55045.2900 205.8000
S 16 50.000000 970.9600 520.0000
H 9060 33943.500000 1709662.8100 440.0000
T 2 3.250000 120.2500 0.0000
15489 18689.000000 792160.5600 831.0800
Other 331 702.250000 48067.3000 1252.2400
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Total 52751 124594.750000 4341723.8500 1342700.7000