CMS/EIP Fiscal Report Center: 52
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 1180 691.750000 25684.2500 37.1294
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 125 74.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1725 8679.750000 321465.6000 37.0363
Subtotal (Total Children Is Unduplicated) 1859 9445.500000 347149.8500 36.7529
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 51 109.000000 7560.5200 69.3626
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 22 44.000000 3300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 8.000000 450.0000 56.2500
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 12.500000 937.5000 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 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 47 94.000000 5217.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 885 1868.000000 132728.8000 71.0540
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 23 46.000000 3450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 359 729.500000 53962.5000 73.9719
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 28 56.000000 4200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 158 334.500000 24437.5000 73.0568
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 33.500000 2172.5000 64.8507
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 871 1745.000000 96381.5000 55.2330
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 22 43.500000 2414.2500 55.5000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 4.000000 205.6400 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 205.2800 51.3200
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
PSTH-97163TLGT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 162 171.000000 8254.0000 48.2690
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 29 33.000000 1583.1000 47.9727
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 27 27.000000 1386.9900 51.3700
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 19 115.250000 4886.8225 42.4019
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 13 78.000000 4121.5400 52.8403
Subtotal (Total Children Is Unduplicated) 1163 5581.750000 359341.8225 64.3780
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 184 241.750000 12063.4300 49.9004
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 185 233.500000 11675.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 90 77.000000 1925.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 186 498.250000 24893.7500 49.9624
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 8 7.750000 387.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 14 10.250000 256.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 81 151.750000 7587.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 8 6.750000 337.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 55 312.250000 15612.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 16 11.250000 562.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 115 203.500000 10175.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 8 7.250000 362.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 344 823.500000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 11 11.500000 575.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 815 9178.250000 453539.0500 49.4145
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 17 18.500000 925.0000 50.0000
INTR-T1013-INTERPRETER 1 3.250000 162.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1028 14403.00000 144012.0000 9.9988
OCCT-97530-OT SESSION BY LICENSED OT 48 377.750000 26227.4700 69.4308
OCCT-97530GT-OT SESSION BY LICENSED OT 4 5.000000 359.2800 71.8560
OCCT-97530HM-OT SESSION BY OT ASST 18 198.000000 10983.3200 55.4713
OCCT-97530TL-OT SESSION BY LICENSED OT 48 500.000000 35913.4400 71.8269
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 5.500000 394.7400 71.7709
OCCT-97530TLGTHM-OT SESSION BY OT ASST 4 6.750000 388.3000 57.5259
OCCT-97530TLHM-OT SESSION BY OT ASST 22 175.000000 10070.0000 57.5429
PHY-97110-PT SESSION BY LICENSED PT 56 461.250000 32991.4600 71.5262
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 143.9200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 25 370.500000 20790.9400 56.1159
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 10 22.250000 1221.6500 54.9056
PHY-97110TL-PT SESSION BY LICENSED PT 43 411.750000 29587.1500 71.8571
PHY-97110TLGT-PT SESSION BY LICENSED PT 3 3.500000 250.5600 71.5886
PHY-97110TLGTHM-PT SESSION BY PT ASST 2 2.000000 115.1200 57.5600
PHY-97110TLHM-PT SESSION BY PT ASST 10 139.750000 8036.0100 57.5028
CMS/EIP Fiscal Report Center: 52
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
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 172 1897.880000 123741.7100 65.2000
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 3.000000 196.3300 65.4433
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 132 1313.500000 94202.5800 71.7188
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 1007 124734.0000 55493.9500 0.4449
Subtotal (Total Children Is Unduplicated) 1373 156832.1300 1136293.8500 7.2453
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Total 171859.380000 1842785.5225 10.7226
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Number of Children (Unduplicated) With at Least One Service 1871
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Center 52
Flag Claims Units Chgs Paid
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R 13 13.000000 685.6200 0.0000
U 0 0.000000 0.0000 0.0000
B 1970 2020.750000 109090.3200 130.2000
P 7562 8189.500000 389453.1100 499472.8900
D 1165 1363.500000 74436.7800 2213.2000
S 603 527.250000 23178.2000 2373.3000
H 444 600.500000 39734.4300 0.0000
T 18352 145957.380000 595599.4700 555102.9700
13063 13177.500000 610134.9925 923.7400
Other 7 10.000000 472.6000 250.0000
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Total 43179 171859.380000 1842785.5225 1060466.3000