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: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 690 1739.000000 64589.4000 37.1417
Subtotal (Total Children Is Unduplicated) 690 1739.000000 64589.4000 37.1417
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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 4 7.500000 562.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 11 19.000000 1425.0000 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 4 7.000000 525.0000 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 8 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 56 99.000000 7425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 37 69.500000 5212.5000 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 40 68.500000 5137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 107 187.500000 10378.5000 55.3520
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 15 27.000000 2025.0000 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-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 201 554.500000 37386.4800 67.4238
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 236 840.250000 42012.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 107 238.000000 11900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 89.000000 6404.4400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 6 9.000000 647.6400 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 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 17 37.150000 2673.2300 71.9577
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 4.980000 357.9800 71.8835
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 55 167.000000 12017.3200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 21 48.750000 3508.0500 71.9600
Subtotal (Total Children Is Unduplicated) 426 1842.130000 108844.8600 59.0864
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Total 4135.630000 210820.7400 50.9767
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Number of Children (Unduplicated) With at Least One Service 829
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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 486 451.500000 24329.7000 0.0000
P 2528 2392.000000 119122.6000 119094.4000
D 18 17.250000 902.0000 0.0000
S 133 145.380000 5835.0900 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
963 985.000000 53947.1500 0.0000
Other 147 121.250000 5780.9000 203.7000
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Total 4302 4135.630000 210820.7400 119298.1000