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
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 2625 3450.000000 128199.9000 37.1594
TCM-T1017TL-TARGETED CASE MANAGEMENT 1271 8835.750000 328247.7000 37.1500
Subtotal (Total Children Is Unduplicated) 3085 12285.75000 456447.6000 37.1526
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 63 66.000000 3300.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 6.500000 325.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 63 51.000000 2550.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 7.500000 562.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 8.500000 637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 9.000000 665.2500 73.9167
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 11.500000 638.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 22 29.000000 1609.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 110 144.500000 10837.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 115 134.000000 10050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 32.500000 2437.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 91 109.000000 8175.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 176 254.500000 14124.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 429 560.000000 31080.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 135 165.000000 12375.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 96 128.500000 9608.2500 74.7724
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 96 96.000000 7139.6000 74.3708
OCTH-97165-OT EVAL LOW COMPLEXITY 8 8.000000 411.2800 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 7 8.000000 411.2800 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 10.000000 514.1000 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 13 15.000000 771.1500 51.4100
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 821 1874.500000 119619.3700 63.8140
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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
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 16 65.000000 3250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 390 7001.500000 349975.0000 49.9857
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 100 637.000000 31800.0000 49.9215
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1916 39570.00000 395462.0000 9.9940
OCCT-97530-OT SESSION BY LICENSED OT 10 117.000000 8419.3200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 11 81.000000 4665.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 11 70.000000 5037.2000 71.9600
PHY-97110HM-PT SESSION BY PT ASST 9 134.500000 7741.8200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 175.000000 12593.0000 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 4.000000 229.6000 57.4000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 2 3.000000 111.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1999 48032.75000 828022.0400 17.2387
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Total 62193.000000 1404089.0100 22.5763
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Number of Children (Unduplicated) With at Least One Service 3467
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Center 04
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 1 0.750000 27.7500 0.0000
P 12950 47960.750000 827583.4200 827568.7200
D 3 7.000000 70.0000 70.0000
S 9 36.000000 520.0000 520.0000
H 20 55.000000 1501.2400 230.0000
T 1 0.250000 9.2500 0.0000
13250 14120.250000 573826.8200 0.0000
Other 6 13.000000 550.5300 71.9600
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Total 26240 62193.000000 1404089.0100 828460.6800