CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 10 8.500000 316.2000 37.2000
Subtotal (Total Children Is Unduplicated) 10 8.500000 316.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 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 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 15.500000 1162.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 20.500000 1537.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.000000 750.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 72 117.500000 6521.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 26 42.500000 2358.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 138.500000 10387.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 111.000000 8325.0000 75.0000
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 2 3.000000 154.2300 51.4100
Subtotal (Total Children Is Unduplicated) 213 493.500000 33696.5500 68.2808
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 43 139.250000 6961.5000 49.9928
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 12 14.000000 700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 3.000000 215.8800 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 19 64.000000 4605.4400 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 5 16.000000 1151.3600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 16 60.000000 4317.6000 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 2.000000 143.9200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 11.000000 791.5600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 287.8400 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 88 314.250000 19247.0600 61.2476
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Total 816.250000 53259.8100 65.2494
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Number of Children (Unduplicated) With at Least One Service 299
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Center 01
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 51 50.750000 2558.4600 0.0000
S 14 15.000000 1044.3800 0.0000
H 558 750.500000 49656.9700 49656.9700
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 623 816.250000 53259.8100 49656.9700