CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2023 ending 09/30/2023 Date of Report:10/10/2023 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 1099 1831.000000 67917.8500 37.0933
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 14 9.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 554 930.000000 34549.5000 37.1500
Subtotal (Total Children Is Unduplicated) 1221 2770.750000 102467.3500 36.9818
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 3 5.000000 250.0000 50.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 12 20.000000 1500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 9.500000 712.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 28 39.000000 2164.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
Subtotal (Total Children Is Unduplicated) 47 104.000000 6807.2500 65.4543
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 2.250000 112.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 12 10.250000 512.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 13 10.750000 537.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 122 98.000000 4900.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 40 57.000000 2850.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 79 52.250000 2612.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 27 31.250000 1562.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 125 59.000000 2937.5000 49.7881
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 36 35.250000 1762.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 123 81.000000 4050.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 2.000000 50.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 368 950.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 141.000000 6750.0000 47.8723
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 17 31.000000 1550.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 466 1877.000000 28155.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 164 459.000000 5508.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 17.000000 1223.3200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 2 5.500000 395.7800 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 2.000000 143.9200 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.500000 35.9800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 29.750000 2140.8100 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
TRAV-TRAVS-Travel by mile 243 12916.00000 5745.7700 0.4449
Subtotal (Total Children Is Unduplicated) 637 16870.00000 73680.0000 4.3675
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Total 19744.750000 182954.6000 9.2660
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Number of Children (Unduplicated) With at Least One Service 1403
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Center 53
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 0 0.000000 0.0000 0.0000
D 175 132.500000 5832.2100 0.0000
S 4 5.500000 232.0500 0.0000
H 1 1.000000 71.9600 0.0000
T 1365 9452.000000 20070.3200 20014.8200
8994 10143.000000 156348.1600 0.0000
Other 18 10.750000 399.9000 0.0000
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Total 10557 19744.750000 182954.6000 20014.8200