CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 529 482.000000 17930.4000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1252 4783.250000 177864.5000 37.1849
Subtotal (Total Children Is Unduplicated) 1283 5265.250000 195794.9000 37.1862
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 8 6.500000 325.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 13.500000 1012.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 21.000000 1575.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 109 152.500000 11437.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 3.500000 262.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 52 67.000000 5025.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 32.500000 1803.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 169 320.500000 17787.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 58.500000 4387.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 129 230.500000 17287.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 47 48.000000 5933.7000 123.6188
OCTH-97165-OT EVAL LOW COMPLEXITY 10 10.000000 514.1000 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 11 11.000000 565.5100 51.4100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 10 10.000000 514.1000 51.4100
Subtotal (Total Children Is Unduplicated) 283 1032.000000 71371.0800 69.1580
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 25 27.250000 1375.0000 50.4587
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 67 3086.000000 77150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1068 7582.000000 379050.0000 49.9934
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 18 89.000000 4450.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 778 5664.000000 84795.0000 14.9709
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 327 2103.000000 25188.0000 11.9772
OCCT-97530-OT SESSION BY LICENSED OT 38 160.000000 11457.5600 71.6098
OCCT-97530HM-OT SESSION BY OT ASST 14 36.000000 1870.7200 51.9644
OCCT-97530TL-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 46 164.000000 11713.6000 71.4244
PHY-97110HM-PT SESSION BY PT ASST 32 135.000000 7770.6000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 199.500000 14356.0200 71.9600
SPL-92508HA-GROUP SPL SESSION PER CHILD 3 6.000000 83.7600 13.9600
Subtotal (Total Children Is Unduplicated) 1231 19255.75000 619548.1000 32.1747
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Total 25553.000000 886714.0800 34.7010
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Number of Children (Unduplicated) With at Least One Service 1720
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Center 04
Flag Claims Units Chgs Paid
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R 89 159.500000 6597.4500 0.0000
U 0 0.000000 0.0000 0.0000
B 1325 2215.000000 86661.4500 0.0000
P 3189 10995.750000 262817.5800 261566.2800
D 21 37.750000 1404.3000 0.0000
S 1 0.250000 9.3000 0.0000
H 1521 5818.500000 292273.4300 225.0000
T 0 0.000000 0.0000 0.0000
2458 6007.750000 215331.3000 0.0000
Other 153 318.500000 21619.2700 727.9300
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Total 8757 25553.000000 886714.0800 262519.2100