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: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 780 2037.500000 75795.0000 37.2000
Subtotal (Total Children Is Unduplicated) 780 2037.500000 75795.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 84 153.000000 11475.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 88 162.500000 12187.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 50 92.000000 6975.0000 75.8152
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 148 267.000000 14847.7500 55.6096
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 34.000000 2550.0000 75.0000
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 123.3700 61.6850
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 5.000000 257.0500 51.4100
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 204 736.500000 49752.5800 67.5527
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 639 3793.000000 189552.0000 49.9742
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 63 140.500000 7025.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 24 124.000000 8923.0400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 8.000000 575.6800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 31 222.000000 15975.1200 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 5.000000 359.8000 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 23 187.000000 13456.5200 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 69.000000 4965.2400 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 706 4551.500000 241048.2800 52.9602
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Total 7325.500000 366595.8600 50.0438
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Number of Children (Unduplicated) With at Least One Service 1073
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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 0 0.000000 0.0000 0.0000
D 6 16.000000 909.8000 0.0000
S 0 0.000000 0.0000 0.0000
H 1996 2201.000000 92140.2000 92140.2000
T 0 0.000000 0.0000 0.0000
1608 4912.250000 260279.5600 130.2000
Other 105 196.250000 13266.3000 0.0000
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Total 3715 7325.500000 366595.8600 92270.4000