CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 634 1521.750000 56507.7000 37.1334
Subtotal (Total Children Is Unduplicated) 634 1521.750000 56507.7000 37.1334
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Screening, Eval, and Assessment,Class #02
AACIS-92597TL-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 103.3600 103.3600
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 14.000000 1050.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 8.500000 471.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 34 61.500000 4612.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 16 31.000000 2325.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 27 46.500000 3487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 57 101.000000 5577.7500 55.2252
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 20.000000 1500.0000 75.0000
SPCH-92521TLGT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 127 333.500000 22658.3200 67.9410
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 108 374.250000 18712.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 38 70.500000 3525.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 4.000000 287.8400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 24 77.500000 5576.9000 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 16 45.500000 3238.2000 71.1692
PHY-97110-PT SESSION BY LICENSED PT 2 8.000000 575.6800 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 43 224.000000 16119.0400 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 16 18.000000 1295.2800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 17.150000 1234.0300 71.9551
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 3.980000 286.0200 71.8643
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 51 148.000000 10650.0800 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 21 48.750000 3508.0500 71.9600
Subtotal (Total Children Is Unduplicated) 237 1041.630000 65152.5400 62.5486
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Total 2896.880000 144318.5600 49.8186
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Number of Children (Unduplicated) With at Least One Service 706
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Center 53
Flag Claims Units Chgs Paid
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R 27 23.250000 903.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 453 415.500000 22439.1400 0.0000
P 2321 2156.000000 107973.2500 107945.0500
D 18 17.250000 902.0000 0.0000
S 110 113.630000 4597.2900 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
85 60.500000 2414.4800 0.0000
Other 141 110.750000 5089.1000 203.7000
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Total 3155 2896.880000 144318.5600 108148.7500