CMS/EIP Fiscal Report Center: 07
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 1631 1655.000000 61584.6000 37.2112
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 121 133.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 667 1320.500000 49030.6000 37.1303
Subtotal (Total Children Is Unduplicated) 1752 3108.750000 110615.2000 35.5819
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 20.000000 1400.0000 70.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 20.000000 1500.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 11.120000 834.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.900200 517.5150 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 102.000000 5661.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 43 86.000000 4773.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 41.532000 3114.9000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 134 333.552200 20944.6950 62.7929
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 56 52.250000 2612.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 86 92.250000 4612.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 10 8.500000 212.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 221 305.750000 15287.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 118 208.750000 10437.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 140 183.250000 9162.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 67 81.250000 4062.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 32 32.500000 1625.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 30 34.500000 1725.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 127 148.500000 7425.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 46 62.750000 3137.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 12 15.000000 375.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 96 124.500000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 432 2264.500000 113225.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 53 114.750000 5737.5000 50.0000
EPIC-99601-Early Steps Professional Development Fee 473 2617.000000 39255.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1214 6947.000000 83370.0000 12.0009
OCCT-97530-OT SESSION BY LICENSED OT 19 70.250000 3376.1800 48.0595
OCCT-97530GT-OT SESSION BY LICENSED OT 1 7.000000 503.7200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 18 71.750000 4190.0100 58.3974
PHY-97110GT-PT SESSION BY LICENSED PT 3 3.000000 54.0800 18.0267
PHY-97110HM-PT SESSION BY PT ASST 1 16.000000 920.9600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 212.500000 13171.7000 61.9845
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 215.8800 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 6.000000 345.6000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 3 21.750000 1252.8000 57.6000
TRAV-TRAVS-Travel by mile 37 1090.000000 470.7100 0.4318
Subtotal (Total Children Is Unduplicated) 1537 14799.25000 326939.1400 22.0916
-----------------------------------------------------------------------------------------------------------------------
Total 18241.552200 458499.0350 25.1349
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2344
-----------------------------------------------------------------------------------------------------------------------
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 10912 15162.750000 337432.4200 337426.4200
D 35 30.000000 1189.2000 0.0000
S 2 0.500000 18.6000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6151 3437.802200 124520.2150 0.0000
Other 144 -389.500000 -4661.4000 -4680.0000
---------------------------------------------------------
Total 17244 18241.552200 458499.0350 332746.4200