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
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
CASE-CASE-NON-TCM CASE MANAGEMENT 529 482.000000 17930.4000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 377 1507.000000 56060.4000 37.2000
Subtotal (Total Children Is Unduplicated) 750 1989.000000 73990.8000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 8 6.500000 325.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 12.000000 900.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.500000 337.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 8.500000 471.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 8.000000 600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 32 45.500000 3412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 19 25.500000 1912.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 10.500000 582.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 45 67.000000 3718.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 13.000000 975.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 45.500000 3412.5000 75.0000
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 89 251.500000 16952.2300 67.4045
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 25 27.250000 1375.0000 50.4587
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 274 2008.000000 100400.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 6 32.000000 1600.0000 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 3 10.000000 663.5600 66.3560
OCCT-97530HM-OT SESSION BY OT ASST 5 8.000000 460.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 8 39.000000 2806.4400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 3 23.000000 1323.8800 57.5600
Subtotal (Total Children Is Unduplicated) 1121 9914.250000 218612.6800 22.0504
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Total 12154.750000 309555.7100 25.4679
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Number of Children (Unduplicated) With at Least One Service 1501
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Center 04
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 2513 9888.250000 218106.1100 218016.1100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 22.000000 288.0000 225.0000
T 0 0.000000 0.0000 0.0000
1815 2237.500000 90788.8000 0.0000
Other 3 7.000000 372.8000 172.8000
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Total 4339 12154.750000 309555.7100 218413.9100