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
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 1113 1957.250000 72660.7000 37.1239
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 20 18.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 529 997.750000 37060.4500 37.1440
Subtotal (Total Children Is Unduplicated) 1222 2973.250000 109721.1500 36.9028
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Screening, Eval, and Assessment,Class #02
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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 30.500000 2287.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 13 23.500000 1762.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 39 69.500000 3857.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 69 160.500000 10384.7300 64.7024
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 71.9600 71.9600
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 357 998.000000 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 61 234.500000 11725.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 18 38.000000 1900.0000 50.0000
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 4 8.000000 575.6800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 5.250000 377.7900 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 37.000000 2662.5200 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 287.8400 71.9600
TRAV-TRAVS-Travel by mile 267 13377.00000 5951.6300 0.4449
Subtotal (Total Children Is Unduplicated) 646 17573.75000 81907.4500 4.6608
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Total 20707.500000 202013.3300 9.7556
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Number of Children (Unduplicated) With at Least One Service 1413
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Center 53
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 1 0.250000 9.3000 0.0000
P 0 0.000000 0.0000 0.0000
D 148 106.000000 4435.8700 0.0000
S 13 6.750000 285.8600 0.0000
H 0 0.000000 0.0000 0.0000
T 1821 12255.500000 31919.5700 31910.2700
8851 8324.250000 164729.8800 0.0000
Other 22 14.750000 632.8500 0.0000
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Total 10856 20707.500000 202013.3300 31910.2700