CMS/EIP Fiscal Report Center: 55
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 2522 4642.500000 172460.1500 37.1481
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 337 372.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2022 9142.250000 339598.3000 37.1460
Subtotal (Total Children Is Unduplicated) 2664 14157.50000 512058.4500 36.1687
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 93 223.691400 11184.5700 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 20 44.000000 2200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 42 78.897400 3944.8700 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 29.587467 2219.0600 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 19.920800 1494.0600 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 191 338.110658 25358.3000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 28 48.003732 3600.2800 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 82.188398 6164.1300 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 11.000000 825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 87.357466 6551.8100 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 15.932133 1194.9100 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 196 398.856216 22136.5200 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 38 76.000000 4218.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 12 11.433967 587.0400 51.3418
OCTH-97165-OT EVAL LOW COMPLEXITY 1 0.085602 4.3700 51.0502
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 1.858588 95.1900 51.2163
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 20 21.805485 1120.6600 51.3935
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.109108 210.7800 51.2958
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 8.000000 410.9200 51.3650
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 14 13.010681 668.8400 51.4070
Subtotal (Total Children Is Unduplicated) 577 1533.849101 95486.1300 62.2526
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 11.000000 11349.0000 1031.7273
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 36 45.750000 2287.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 2 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 159 256.750000 12837.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 20 40.000000 2000.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 88 211.250000 5281.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 47 131.500000 6575.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 58 311.000000 7775.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 7.000000 350.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 152 241.750000 12087.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 20 38.000000 1900.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 82 170.250000 4256.2500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 42.000000 2100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 194 2816.250000 140812.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 16 139.000000 6950.0000 50.0000
INTR-T1013-INTERPRETER 2 4.500000 570.0000 126.6667
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1075 22606.00000 225990.0000 9.9969
OCCT-97530-OT SESSION BY LICENSED OT 51 444.260346 31958.4100 71.9362
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 55 705.868808 40615.6400 57.5399
OCCT-97530HMGT-OT SESSION BY OT ASST 2 11.750000 676.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 40 473.240035 34036.2800 71.9218
PHY-97110HM-PT SESSION BY PT ASST 26 348.442645 20042.7600 57.5210
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 111 952.415774 68479.5600 71.9009
TRAV-TRAVS-Travel by mile 113 10964.00000 4876.8200 0.4448
Subtotal (Total Children Is Unduplicated) 1170 40976.97761 644101.6900 15.7186
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Total 56668.326709 1251646.2700 22.0872
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Number of Children (Unduplicated) With at Least One Service 2700
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Center 55
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 29749 37891.092054 613146.7900 613113.1900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
24351 18777.234655 638499.4800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 54100 56668.326709 1251646.2700 613113.1900