CMS/EIP Fiscal Report Center: 10
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 1335 4267.250000 158695.2000 37.1891
Subtotal (Total Children Is Unduplicated) 1335 4267.250000 158695.2000 37.1891
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 10.500000 787.5000 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 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 112.500000 8437.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 19 37.000000 2775.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.500000 862.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 19.000000 1425.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 19.000000 1425.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 87.500000 4856.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 43.000000 2425.5000 56.4070
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 30.000000 2325.0000 77.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 10 13.000000 668.3300 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 110 401.500000 27148.3100 67.6172
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 6.000000 1419.1000 236.5167
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 49 47.250000 2362.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 265 234.000000 11700.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 19 12.250000 306.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 57 85.000000 4250.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 238 354.500000 17725.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 10.000000 500.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 29 39.750000 1987.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 8.750000 437.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 80 110.750000 5537.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 28 37.000000 1850.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 141 205.750000 10287.5000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.000000 150.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 10.000000 500.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 420 3271.500000 163575.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 226 1121.750000 56087.5000 50.0000
EPIC-99601-Early Steps Professional Development Fee 349 2835.000000 42237.0000 14.8984
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1227 11471.00000 137652.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 59 265.750000 19123.3700 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 0.500000 35.9800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 9 40.500000 2310.4000 57.0469
PHY-97110-PT SESSION BY LICENSED PT 54 232.500000 16730.7000 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 2 3.500000 251.8600 71.9600
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.5600 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 7.000000 402.9200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 170 957.000000 68865.7200 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 17 40.500000 2914.3800 71.9600
Subtotal (Total Children Is Unduplicated) 1727 21411.50000 569257.2400 26.5865
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Total 26080.250000 755100.7500 28.9530
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Number of Children (Unduplicated) With at Least One Service 2445
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Center 10
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 10118 21368.750000 568643.8700 568643.8700
D 9 12.250000 235.3000 0.0000
S 40 45.750000 1159.9300 100.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5371 4653.500000 185061.6500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15538 26080.250000 755100.7500 568743.8700