CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 14 36.500000 1357.8000 37.2000
Subtotal (Total Children Is Unduplicated) 14 36.750000 1367.1000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 223.5000 63.8571
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 40 68.000000 5062.5000 74.4485
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 17 31.000000 2325.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 27.500000 2062.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 37 61.500000 3405.0000 55.3659
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 82 204.000000 13867.2300 67.9766
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 2 3.000000 215.8800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 3.000000 215.8800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 6.000000 431.7600 71.9600
Subtotal (Total Children Is Unduplicated) 6 14.000000 1007.4400 71.9600
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Total 254.750000 16241.7700 63.7557
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Number of Children (Unduplicated) With at Least One Service 99
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Center 09
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 39 39.500000 1567.3400 1567.3400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 95 154.000000 10400.9300 10400.9300
T 0 0.000000 0.0000 0.0000
36 61.250000 4273.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 170 254.750000 16241.7700 11968.2700