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
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 760 2459.250000 91381.8000 37.1584
Subtotal (Total Children Is Unduplicated) 760 2459.250000 91381.8000 37.1584
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Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 103.3600 103.3600
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 6 10.500000 787.5000 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 2 4.000000 300.0000 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 12 23.000000 1725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 31 60.000000 4500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 15.000000 1125.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 20 39.500000 2192.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 18.000000 1350.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 38.000000 2850.0000 75.0000
Subtotal (Total Children Is Unduplicated) 111 279.500000 19985.7200 71.5053
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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 83 321.500000 16075.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 33 88.000000 4400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 6.000000 431.7600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 60 171.980000 12374.3000 71.9520
OCCT-97530TLGT-OT SESSION BY LICENSED OT 20 44.000000 3166.2400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 5 7.000000 503.7200 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 43 163.750000 11783.4500 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-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 18 62.890000 4524.2300 71.9388
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 2.500000 179.9000 71.9600
Subtotal (Total Children Is Unduplicated) 222 886.120000 54552.4700 61.5633
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Total 3624.870000 165919.9900 45.7727
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Number of Children (Unduplicated) With at Least One Service 782
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Center 54
Flag Claims Units Chgs Paid
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R 27 23.250000 899.6600 0.0000
U 0 0.000000 0.0000 0.0000
B 565 527.250000 24092.0900 0.0000
P 3305 2940.500000 134231.4100 134227.9100
D 1 0.500000 18.6000 0.0000
S 19 18.140000 1242.5300 0.0000
H 7 5.480000 392.9600 0.0000
T 0 0.000000 0.0000 0.0000
20 23.500000 940.3600 0.0000
Other 106 86.250000 4102.3800 0.0000
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Total 4050 3624.870000 165919.9900 134227.9100