CMS/EIP Fiscal Report Center: 05
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: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 526 218.250000 8118.9000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 185 167.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 521 1264.250000 47030.1000 37.2000
Subtotal (Total Children Is Unduplicated) 810 1649.500000 55149.0000 33.4338
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 9.500000 527.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 10.500000 582.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 72.000000 5400.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 30 51.000000 3825.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 28.500000 2137.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 32.500000 2437.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 18.000000 1350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 65.000000 3607.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 25 42.000000 2331.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 105.2300 35.0767
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 5 14.000000 488.7100 34.9079
Subtotal (Total Children Is Unduplicated) 146 381.000000 25205.1300 66.1552
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.000000 1216.0800 405.3600
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 75 79.750000 3987.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 13 15.750000 787.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 86 121.000000 6050.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 6 6.000000 300.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 32 33.000000 1650.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 45 80.000000 4000.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 20 20.250000 1012.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 2 1.500000 75.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 30 28.250000 1412.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 9 7.500000 375.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 6.000000 150.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 16.000000 800.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 148 723.000000 36150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 10 19.500000 975.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 339 1976.000000 29628.0000 14.9939
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 337 1387.000000 16644.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 158.500000 10786.9100 68.0562
PHY-97110-PT SESSION BY LICENSED PT 10 22.000000 1283.2500 58.3295
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 83.500000 5385.9400 64.5023
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 7.750000 557.6900 71.9600
TRAV-TRAVS-Travel by mile 535 48562.00000 21616.1800 0.4451
Subtotal (Total Children Is Unduplicated) 642 53363.75000 145130.5500 2.7196
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Total 55394.250000 225484.6800 4.0705
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Number of Children (Unduplicated) With at Least One Service 1031
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Center 05
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 4891 51147.250000 160717.9400 160717.9400
D 6 3.000000 111.6000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3422 4243.250000 64627.2400 9614.7400
Other 1 0.750000 27.9000 0.0000
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Total 8320 55394.250000 225484.6800 170332.6800