CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 25.000000 1875.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 36 36.000000 1998.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 18.500000 1054.5000 57.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 37.000000 2775.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 15.500000 1162.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 11 11.000000 565.5100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 9 18.000000 915.0000 50.8333
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 116 174.500000 11220.5600 64.3012
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EI Services,Class #03
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 1 0.750000 37.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 109 559.250000 27798.0000 49.7059
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 29.000000 1450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 455 2712.000000 32714.0000 12.0627
OCCT-97530-OT SESSION BY LICENSED OT 76 356.750000 25429.9700 71.2823
OCCT-97530GT-OT SESSION BY LICENSED OT 5 14.250000 1007.4400 70.6975
OCCT-97530HM-OT SESSION BY OT ASST 49 309.750000 17510.9200 56.5324
OCCT-97530HMGT-OT SESSION BY OT ASST 2 5.000000 288.0000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 1 5.250000 377.7900 71.9600
OCCT-97530TLHM-OT SESSION BY OT ASST 2 6.000000 345.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 37 134.000000 9514.2800 71.0021
PHY-97110GT-PT SESSION BY LICENSED PT 2 3.500000 251.8600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 129 656.500000 46219.9400 70.4036
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 18.000000 1295.2800 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 6.000000 431.7600 71.9600
Subtotal (Total Children Is Unduplicated) 465 4819.000000 164822.3400 34.2026
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Total 4993.500000 176042.9000 35.2544
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Number of Children (Unduplicated) With at Least One Service 511
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Center 51
Flag Claims Units Chgs Paid
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R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 10 9.000000 527.2500 0.0000
P 1354 3968.500000 114882.2200 114782.2200
D 0 0.000000 0.0000 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
321 1015.000000 60577.9300 45.0000
Other 0 0.000000 0.0000 0.0000
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Total 1686 4993.500000 176042.9000 114827.2200