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:OTHER
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 124 245.750000 9160.5000 37.2757
Subtotal (Total Children Is Unduplicated) 124 245.750000 9160.5000 37.2757
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 21.500000 1612.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 40 64.000000 4800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 44 54.000000 4050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 28.000000 2100.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 23.000000 1276.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 83 115.500000 6410.2500 55.5000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 3.000000 150.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 13 48.000000 2400.0000 50.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 3 9.000000 462.6900 51.4100
Subtotal (Total Children Is Unduplicated) 146 395.500000 25230.6900 63.7944
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 13 18.500000 925.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 5 8.000000 400.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 28 29.500000 737.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 3 4.000000 200.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 5.750000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 223 1188.000000 59250.0000 49.8737
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 11 27.000000 1350.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 261 1387.000000 6855.0000 4.9423
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 95 359.000000 4446.0000 12.3844
OCCT-97530-OT SESSION BY LICENSED OT 25 87.000000 6260.5200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 18 73.000000 5149.4200 70.5400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 62 241.000000 17342.3600 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 13.000000 935.4800 71.9600
TRAV-TRAVS-Travel by mile 405 20816.00000 9202.4500 0.4421
Subtotal (Total Children Is Unduplicated) 496 24272.75000 113941.5700 4.6942
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Total 24914.000000 148332.7600 5.9538
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Number of Children (Unduplicated) With at Least One Service 636
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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 1645 21667.750000 104650.8500 104650.8500
D 12 125.000000 549.8600 0.0000
S 0 0.000000 0.0000 0.0000
H 319 439.000000 24683.2500 0.0000
T 0 0.000000 0.0000 0.0000
237 2677.250000 18073.8000 0.0000
Other 3 5.000000 375.0000 0.0000
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Total 2216 24914.000000 148332.7600 104650.8500