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
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 1456 3277.500000 121923.0000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 735 2100.500000 78138.6000 37.2000
Subtotal (Total Children Is Unduplicated) 1624 5378.000000 200061.6000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 120 206.000000 10300.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 53 95.000000 7095.7500 74.6921
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 77 144.000000 10800.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 31 55.000000 4125.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 116 209.500000 11666.2500 55.6862
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 35.000000 2625.0000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 10 38.000000 1900.0000 50.0000
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
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 10 40.000000 2056.4000 51.4100
Subtotal (Total Children Is Unduplicated) 320 839.500000 51644.6300 61.5183
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 61 105.250000 5262.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 31 49.000000 2450.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 84 115.500000 2912.5000 25.2165
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 13 14.000000 700.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 3 3.000000 150.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 17 17.000000 850.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 3 3.000000 150.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 10 10.000000 500.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 11.000000 550.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 5 5.000000 250.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 34 79.250000 0.5000 0.0063
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 391 1925.000000 96250.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 16 33.000000 1650.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 608 3634.000000 24138.1000 6.6423
INTR-T1013-INTERPRETER 93 382.750000 19137.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 358 1968.000000 24042.0000 12.2165
OCCT-97530-OT SESSION BY LICENSED OT 28 116.000000 8347.3600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.750000 125.9300 71.9600
PHY-97110-PT SESSION BY LICENSED PT 29 166.000000 11945.3600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 250.000000 17846.0800 71.3843
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 11 49.000000 3526.0400 71.9600
TRAV-TRAVS-Travel by mile 1176 90447.00000 40171.8600 0.4441
Subtotal (Total Children Is Unduplicated) 1326 99387.50000 261080.7300 2.6269
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Total 105605.000000 512786.9600 4.8557
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Number of Children (Unduplicated) With at Least One Service 2008
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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 9772 98412.500000 466866.2200 466866.2200
D 134 1347.000000 3860.9200 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
1027 5804.500000 39395.5700 0.0000
Other 23 41.000000 2664.2500 0.0000
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Total 10956 105605.000000 512786.9600 466866.2200