CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
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 227 140.750000 5235.9000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 959 1889.500000 70289.4000 37.2000
Subtotal (Total Children Is Unduplicated) 1032 2031.250000 75525.3000 37.1817
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 56 96.000000 7158.6300 74.5691
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 75.000000 5523.9400 73.6525
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 21.000000 1396.9300 66.5205
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 97 184.500000 10295.2500 55.8008
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 15.500000 860.2500 55.5000
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 257.0500 51.4100
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 193 437.500000 28022.4000 64.0512
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 122 131.250000 6325.0000 48.1905
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 19 16.000000 800.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 5.000000 250.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 38 50.750000 2537.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 4 5.000000 250.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 31 39.750000 1987.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 75 105.000000 5250.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 16 20.000000 1000.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 8 14.000000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 2.000000 100.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 189 738.250000 36912.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 16.000000 800.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 219 906.000000 13590.0000 15.0000
INTR-T1013-INTERPRETER 15 93.250000 4735.0000 50.7775
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 368 1585.000000 19009.0000 11.9931
OCCT-97530-OT SESSION BY LICENSED OT 7 23.750000 1709.0500 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 3 6.000000 431.7600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 33 96.750000 6560.1100 67.8048
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 166.750000 11172.8300 67.0035
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
TRAV-TRAVS-Travel by mile 472 42579.00000 18940.1400 0.4448
Subtotal (Total Children Is Unduplicated) 641 46603.50000 132604.3100 2.8454
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Total 49072.250000 236152.0100 4.8123
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Number of Children (Unduplicated) With at Least One Service 1232
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Center 03
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 871 6340.000000 19150.1300 19150.1300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 21 241.000000 634.1200 634.1200
T 0 0.000000 0.0000 0.0000
8503 42491.250000 216367.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9395 49072.250000 236152.0100 19784.2500