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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 914 3421.250000 127198.1000 37.1788
Subtotal (Total Children Is Unduplicated) 914 3421.250000 127198.1000 37.1788
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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 82 112.500000 8437.5000 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 40 49.500000 3712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 25.500000 1415.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 129 182.000000 10101.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 36.500000 2737.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 81 119.500000 8962.5000 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) 191 573.000000 38467.6500 67.1338
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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 9781.750000 457188.4900 46.7389
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Number of Children (Unduplicated) With at Least One Service 1244
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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 674 1089.250000 42123.4600 41388.0500
D 22 38.750000 1479.3000 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
290 367.250000 23642.3500 0.0000
Other 15 21.000000 781.2000 0.0000
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Total 3983 9781.750000 457188.4900 41388.0500