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: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 546 509.500000 18953.4000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1292 5041.500000 187471.4000 37.1856
Subtotal (Total Children Is Unduplicated) 1323 5551.000000 206424.8000 37.1870
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 9 7.500000 375.0000 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 20 22.000000 1650.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 120 165.000000 12375.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 6.000000 450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 64 81.500000 6112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 34 44.000000 2442.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 188 357.000000 19813.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 68.000000 5100.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 141 246.500000 18487.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 51 52.000000 6466.1500 124.3490
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) 313 1141.000000 78817.5300 69.0776
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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 25947.750000 904790.4300 34.8697
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Number of Children (Unduplicated) With at Least One Service 1762
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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 1379 2309.250000 90570.0000 0.0000
P 3223 11052.000000 265088.1300 263836.8300
D 22 38.750000 1479.3000 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
2626 6249.500000 227097.7500 0.0000
Other 154 320.000000 21675.0700 727.9300
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Total 9015 25947.750000 904790.4300 264789.7600