CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 807 2851.750000 105973.5000 37.1609
Subtotal (Total Children Is Unduplicated) 807 2851.750000 105973.5000 37.1609
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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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 15.500000 860.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 32.500000 2437.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 18.000000 1350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 49 93.000000 6975.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.000000 825.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 17 32.500000 2437.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 8.500000 471.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 39 77.000000 4273.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 28.000000 2100.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 70.000000 5250.0000 75.0000
Subtotal (Total Children Is Unduplicated) 175 428.000000 30158.8600 70.4646
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 42.4100 42.4100
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 83 316.500000 15825.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 33 88.000000 4400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 57 161.750000 11639.5300 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 17 38.000000 2734.4800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 4 5.000000 359.8000 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 43 162.750000 11711.4900 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 10 11.500000 827.5400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 16 59.250000 4263.6300 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 1.500000 107.9400 71.9600
Subtotal (Total Children Is Unduplicated) 213 852.250000 52227.7000 61.2821
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Total 4132.000000 188360.0600 45.5857
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Number of Children (Unduplicated) With at Least One Service 832
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Center 54
Flag Claims Units Chgs Paid
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R 33 29.000000 1113.5600 0.0000
U 0 0.000000 0.0000 0.0000
B 627 608.750000 27687.8900 0.0000
P 3735 3494.250000 159558.6100 159555.1100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4395 4132.000000 188360.0600 159555.1100