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:MED
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 442 1050.750000 38957.7000 37.0761
Subtotal (Total Children Is Unduplicated) 442 1050.750000 38957.7000 37.0761
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 76 149.000000 11175.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 12 24.000000 1800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 54.000000 4050.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 38.000000 2850.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 83 166.000000 9213.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 10 10.000000 500.0000 50.0000
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 3 13.000000 668.3300 51.4100
Subtotal (Total Children Is Unduplicated) 131 497.000000 33098.5600 66.5967
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 271 1208.250000 60412.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 17 69.500000 3500.0000 50.3597
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 2 2.000000 115.2000 57.6000
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 3 3.000000 215.8800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.5600 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-92507TL-SPL THERAPY SESSION BY LICENSED SLP 43 171.500000 12341.1400 71.9600
Subtotal (Total Children Is Unduplicated) 341 1629.500000 88720.9100 54.4467
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Total 3177.250000 160777.1700 50.6026
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Number of Children (Unduplicated) With at Least One Service 547
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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 1357 1366.250000 65144.7600 64980.4200
D 0 0.000000 0.0000 0.0000
S 214 208.000000 8701.8000 210.0200
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.6000 0.0000
888 893.750000 50473.5100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3146 3177.250000 160777.1700 65364.7000