CMS/EIP Fiscal Report Center: 52
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
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 403 166.500000 6175.2000 37.0883
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 40 22.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 805 1951.500000 72493.5000 37.1476
Subtotal (Total Children Is Unduplicated) 929 2140.750000 78668.7000 36.7482
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 22.000000 1650.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 18.000000 999.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 157 323.500000 23433.3000 72.4368
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 25 50.000000 3750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 72 145.000000 10671.2000 73.5945
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 22.000000 1650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 76.000000 5535.0200 72.8292
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 186 369.500000 20507.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 13 13.000000 650.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 12 55.000000 2416.2700 43.9322
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 3 13.000000 668.3300 51.4100
Subtotal (Total Children Is Unduplicated) 261 1137.000000 73921.8300 65.0148
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 49 59.500000 3025.0000 50.8403
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 20 15.500000 775.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 24 18.250000 456.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 72 209.250000 10462.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 3 2.750000 137.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 28 33.500000 1675.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 38 66.250000 3312.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 2.500000 62.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 32 38.750000 1937.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 1 0.250000 12.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 152 1520.500000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 479 2128.000000 106400.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 33 140.500000 7050.0000 50.1779
EPIC-99601-Early Steps Professional Development Fee 157 688.000000 10320.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 467 2320.000000 27840.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 18 101.000000 7267.9600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 10 16.000000 864.0000 54.0000
OCCT-97530TL-OT SESSION BY LICENSED OT 18 64.250000 4623.4300 71.9600
OCCT-97530TLHM-OT SESSION BY OT ASST 6 10.000000 576.0000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 47 163.000000 11729.4800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 14 50.000000 2820.4400 56.4088
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 3 4.000000 230.2400 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 20 76.000000 5468.9600 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 6 22.000000 1266.3200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 83 358.250000 25115.9100 70.1072
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 35.9800 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 43 171.500000 12341.1400 71.9600
TRAV-TRAVS-Travel by mile 392 27323.00000 12155.8400 0.4449
Subtotal (Total Children Is Unduplicated) 719 35607.50000 258149.4500 7.2499
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Total 38885.250000 410739.9800 10.5629
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Number of Children (Unduplicated) With at Least One Service 1071
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Center 52
Flag Claims Units Chgs Paid
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R 44 41.250000 2184.6600 0.0000
U 0 0.000000 0.0000 0.0000
B 642 667.500000 34253.8400 174.2600
P 1439 1458.750000 71322.0600 69967.9700
D 86 89.750000 6537.6500 0.0000
S 361 295.750000 11845.2000 210.0200
H 97 125.750000 9156.2000 0.0000
T 6393 31883.750000 142154.6300 133166.6200
3738 4322.750000 133285.7400 346.4300
Other 0 0.000000 0.0000 0.0000
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Total 12800 38885.250000 410739.9800 203865.3000