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:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 19 14.500000 539.4000 37.2000
Subtotal (Total Children Is Unduplicated) 19 14.500000 539.4000 37.2000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
EXIT-EXIT-COS Exit 30 24.250000 1212.5000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
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 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 11.500000 862.5000 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 5 7.500000 562.5000 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 16 26.500000 1470.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 21.000000 1575.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 20.000000 1500.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 3 11.000000 586.0600 53.2782
Subtotal (Total Children Is Unduplicated) 80 151.250000 9651.7200 63.8130
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 89 103.500000 5000.0000 48.3092
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 71 80.250000 4012.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 23 24.500000 662.5000 27.0408
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 108 173.500000 6975.0000 40.2017
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 85 154.750000 5287.5000 34.1680
CONIP-CONIP-CONSULT, ITDS PHONE 5 4.500000 112.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 48 50.750000 2537.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 46 52.750000 2637.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 9 6.500000 162.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 57 77.750000 3887.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 31 33.000000 1650.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 7.000000 175.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 105 139.250000 6962.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 25 28.000000 1400.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 5.000000 175.0000 35.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 21.000000 1050.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 120 412.500000 20625.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 13 22.250000 1112.5000 50.0000
EPIC-99601-Early Steps Professional Development Fee 108 308.000000 4620.0000 15.0000
INTR-T1013-INTERPRETER 103 240.000000 11743.5000 48.9313
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1437 7316.000000 87590.0000 11.9724
OCCT-97530-OT SESSION BY LICENSED OT 5 22.000000 1583.1200 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 3 6.000000 431.7600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 17 49.000000 3076.4900 62.7855
PHY-97110TL-PT SESSION BY LICENSED PT 3 18.000000 1295.2800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 50.250000 3511.5200 69.8810
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 19.000000 1367.2400 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
SPL-92508HA-GROUP SPL SESSION PER CHILD 1 5.000000 69.8000 13.9600
TRAV-TRAVS-Travel by mile 450 23308.00000 10316.3700 0.4426
Subtotal (Total Children Is Unduplicated) 1646 32739.00000 190102.0400 5.8066
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Total 32904.750000 200293.1600 6.0871
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Number of Children (Unduplicated) With at Least One Service 1691
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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 1 1.500000 75.0000 75.0000
P 6318 19899.500000 104244.4500 104244.4500
D 146 426.500000 2907.2700 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4621 12228.250000 73591.1200 73591.1200
329 349.000000 19475.3200 12.0000
Other 0 0.000000 0.0000 0.0000
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Total 11415 32904.750000 200293.1600 177922.5700