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:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 891 3276.250000 121804.1000 37.1779
Subtotal (Total Children Is Unduplicated) 891 3276.250000 121804.1000 37.1779
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Screening, Eval, and Assessment,Class #02
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 2 1.500000 112.5000 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 3 3.500000 262.5000 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 3 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 13.000000 975.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 74 103.000000 7725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 32 40.000000 3000.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 22.000000 1221.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 115 165.000000 9157.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 34.500000 2587.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 73 110.500000 8287.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 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 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 173 522.500000 35079.9000 67.1386
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 810 5574.000000 278650.0000 49.9910
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 12 57.000000 2850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 46.000000 3310.1600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 6 21.000000 1209.6000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 5 24.000000 1639.2000 68.3000
PHY-97110HM-PT SESSION BY PT ASST 8 59.000000 3396.0400 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.500000 179.9000 71.9600
Subtotal (Total Children Is Unduplicated) 831 5787.500000 291522.7400 50.3711
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Total 9586.250000 448406.7400 46.7760
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Number of Children (Unduplicated) With at Least One Service 1218
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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 640 1033.000000 39852.9100 39117.5000
D 21 37.750000 1404.3000 0.0000
S 1 0.250000 9.3000 0.0000
H 1513 5796.500000 291985.4300 0.0000
T 0 0.000000 0.0000 0.0000
262 324.750000 21170.5000 0.0000
Other 14 19.500000 725.4000 0.0000
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Total 3865 9586.250000 448406.7400 39117.5000