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
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 1180 691.750000 25684.2500 37.1294
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 125 74.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 743 3672.250000 135907.2000 37.0092
Subtotal (Total Children Is Unduplicated) 1484 4438.000000 161591.4500 36.4109
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 60.000000 2922.0000 48.7000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 34.000000 2500.0000 73.5294
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 62.000000 3441.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 56 182.000000 10636.4100 58.4418
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 183 240.500000 12000.9300 49.8999
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 81 150.500000 7525.0000 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 115 202.500000 10125.0000 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 344 820.250000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 37 155.000000 7607.8000 49.0826
INTR-T1013-INTERPRETER 1 3.250000 162.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1028 14387.00000 143862.0000 9.9994
OCCT-97530-OT SESSION BY LICENSED OT 1 13.000000 935.4800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 2 4.000000 230.4000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 1 3.000000 215.3600 71.7867
PHY-97110-PT SESSION BY LICENSED PT 2 2.500000 179.3800 71.7520
PHY-97110HM-PT SESSION BY PT ASST 2 8.000000 210.3800 26.2975
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.000000 7.7800 7.7800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 46.750000 3156.0500 67.5091
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
TRAV-TRAVS-Travel by mile 1007 124715.0000 55488.6100 0.4449
Subtotal (Total Children Is Unduplicated) 1372 141922.0000 297975.5900 2.0996
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Total 146542.000000 470203.4500 3.2087
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Number of Children (Unduplicated) With at Least One Service 1768
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Center 52
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 2.000000 111.0000 0.0000
P 2 0.500000 18.5500 18.5500
D 77 97.750000 5189.8500 0.0000
S 25 15.000000 650.0000 0.0000
H 1 3.000000 111.0000 0.0000
T 14671 140611.750000 290638.0500 285289.4400
8995 5804.000000 173162.4000 221.2000
Other 6 8.000000 322.6000 100.0000
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Total 23778 146542.000000 470203.4500 285629.1900