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
Payclass Filters:GR
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 368 899.250000 33480.0000 37.2310
Subtotal (Total Children Is Unduplicated) 671 1088.500000 39655.2000 36.4311
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 94.000000 5217.0000 55.5000
Subtotal (Total Children Is Unduplicated) 50 120.000000 7089.0000 59.0750
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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 19 15.000000 750.0000 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 26 31.500000 1575.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 37 65.250000 3262.5000 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 1520.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 31 132.250000 6612.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 5.000000 250.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 156 687.000000 10305.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 467 2316.000000 27792.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 6.000000 431.7600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 287.8400 71.9600
TRAV-TRAVS-Travel by mile 390 27200.00000 12101.1200 0.4449
Subtotal (Total Children Is Unduplicated) 718 32315.00000 79498.9700 2.4601
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Total 33523.500000 126243.1700 3.7658
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Number of Children (Unduplicated) With at Least One Service 984
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Center 52
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 7 9.000000 637.2000 0.0000
S 147 87.750000 3143.4000 0.0000
H 0 0.000000 0.0000 0.0000
T 5289 30704.500000 75406.9700 73652.9700
2319 2722.250000 47055.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7762 33523.500000 126243.1700 73652.9700