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
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 1113 1957.250000 72660.7000 37.1239
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 20 18.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1187 2747.750000 102059.0500 37.1428
Subtotal (Total Children Is Unduplicated) 1348 4723.250000 174719.7500 36.9914
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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
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 8.8100 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 14 24.500000 1837.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 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 11 21.500000 1193.2500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 22.500000 1687.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 82 148.000000 11100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 13.500000 1012.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 55 107.000000 8062.5000 75.3505
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 62 106.000000 7950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 157 291.500000 16150.5000 55.4048
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 33.000000 2475.0000 75.0000
SPCH-92521TLGT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92610TL-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 257.0500 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 291 843.000000 56540.0100 67.0700
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 2031.9600 1015.9800
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 9 7.750000 387.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 19 14.250000 712.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 8 8.500000 425.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 95 52.000000 2600.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 33 42.000000 2037.5000 48.5119
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 64 54.750000 2687.5000 49.0868
CONPF-CONPF-CONSULT, PT, FACE TO FACE 25 43.000000 2150.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 133 66.250000 3312.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 3.000000 75.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 41 51.250000 2537.5000 49.5122
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 154 119.500000 5975.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 357 1000.500000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 321 1165.250000 58262.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 132 289.000000 14437.2000 49.9557
EPIC-99601-Early Steps Professional Development Fee 476 2064.000000 30960.0000 15.0000
INTR-T1013-INTERPRETER 5 4.750000 257.1100 54.1284
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 154 337.000000 4044.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 52 229.000000 16478.8400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 17 32.500000 2338.7000 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 33 109.500000 7879.6200 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 18 47.500000 3382.1200 71.2025
PHY-97110-PT SESSION BY LICENSED PT 28 120.000000 8803.2400 73.3603
PHY-97110GT-PT SESSION BY LICENSED PT 6 5.250000 377.7900 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 43 225.000000 16191.0000 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 16 18.000000 1295.2800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 215.500000 15507.3800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 19.250000 1385.2300 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 56 171.000000 12305.1600 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 21 48.750000 3508.0500 71.9600
TRAV-TRAVS-Travel by mile 267 13377.00000 5951.6300 0.4449
Subtotal (Total Children Is Unduplicated) 681 19944.00000 228346.8100 11.4494
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Total 25510.250000 459606.5700 18.0165
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Number of Children (Unduplicated) With at Least One Service 1489
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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 487 451.750000 24339.0000 0.0000
P 2539 2398.680000 119772.6800 119580.0800
D 285 245.690000 13326.9900 0.0000
S 146 152.130000 6120.9500 0.0000
H 92 95.000000 6806.4700 0.0000
T 1875 12311.000000 36645.7800 36636.4800
10177 9696.750000 245277.6500 0.0000
Other 169 136.000000 6413.7500 203.7000
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Total 15797 25510.250000 459606.5700 156420.2600