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
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
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 16 10.250000 381.3000 37.2000
Subtotal (Total Children Is Unduplicated) 16 10.250000 381.3000 37.2000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EXIT-EXIT-COS Exit 3 2.250000 112.5000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 10.000000 750.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 12.500000 937.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 7.000000 380.4200 54.3457
Subtotal (Total Children Is Unduplicated) 32 75.750000 5112.6700 67.4940
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 14.000000 700.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 13 13.750000 687.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 2.500000 62.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 10 15.000000 750.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 10 12.750000 637.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 10 12.000000 600.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 9 6.500000 162.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 35 55.750000 2787.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 5 5.000000 250.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 7.000000 175.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 22 30.250000 1512.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 3 5.000000 250.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 7.000000 350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 1.750000 87.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 13.000000 935.4800 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 3 6.000000 431.7600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 3 6.000000 431.7600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 3 18.000000 1295.2800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 359.8000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 121 242.250000 12735.5000 52.5717
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Total 328.250000 18229.4700 55.5353
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Number of Children (Unduplicated) With at Least One Service 163
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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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3 4.000000 216.5000 216.5000
308 324.250000 18012.9700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 311 328.250000 18229.4700 216.5000