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
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 227 140.750000 5235.9000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 411 701.750000 26105.1000 37.2000
Subtotal (Total Children Is Unduplicated) 566 843.500000 31341.0000 37.1559
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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 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 41.500000 3112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 28.500000 2137.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 49 90.500000 5078.2500 56.1133
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 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
Subtotal (Total Children Is Unduplicated) 103 204.500000 13080.5100 63.9634
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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 170 688.500000 34425.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 13.000000 650.0000 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 6 18.000000 1295.2800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 5.000000 359.8000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 20 53.000000 3813.8800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 112.750000 7793.6100 69.1229
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
TRAV-TRAVS-Travel by mile 472 42579.00000 18940.1400 0.4448
Subtotal (Total Children Is Unduplicated) 632 46445.25000 123283.6700 2.6544
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Total 47493.250000 167705.1800 3.5311
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Number of Children (Unduplicated) With at Least One Service 948
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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 853 6320.500000 17949.7900 17949.7900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 238.000000 484.1200 484.1200
T 0 0.000000 0.0000 0.0000
6580 40934.750000 149271.2700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7451 47493.250000 167705.1800 18433.9100