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: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 664 486.500000 18097.8000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 90 75.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 756 2011.250000 74745.1000 37.1635
Subtotal (Total Children Is Unduplicated) 1151 2572.750000 92842.9000 36.0870
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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
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 16 17.000000 824.5000 48.5000
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 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 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 3 6.000000 333.0000 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 13.500000 1012.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 15.000000 1125.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 17 33.000000 2475.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 24.000000 1800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 21.500000 1193.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 37 73.500000 4079.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 21.500000 1612.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 29.500000 2212.5000 75.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 110 292.000000 19405.3600 66.4567
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 4 4.000000 169.6400 42.4100
ASST-ASST-ASSISTIVE TECHNOLOGY 18 30.000000 2352.7200 78.4240
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 45 44.500000 2225.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 117 131.000000 6550.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.500000 12.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 48 51.750000 2587.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 196 105.000000 5225.0000 49.7619
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 45 47.500000 2375.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 239 109.750000 5462.5000 49.7722
CONOP-CONOP-CONSULT, OT, PHONE 2 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 36 39.500000 1975.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 138 53.500000 2675.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 39 56.000000 2800.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 163 80.750000 4037.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 1.750000 43.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 446 1407.750000 228.5000 0.1623
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 66 210.750000 10537.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 42 84.500000 4225.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 563 2054.000000 30810.0000 15.0000
INTR-T1013-INTERPRETER 13 29.000000 984.9900 33.9652
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 328 1134.000000 13646.0000 12.0335
OCCT-97530-OT SESSION BY LICENSED OT 23 83.000000 5972.6800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 7 10.000000 719.6000 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 14 55.000000 3957.8000 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 143.9200 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 91.750000 6602.3300 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
TRAV-TRAVS-Travel by mile 437 20917.00000 9304.7300 0.4448
Subtotal (Total Children Is Unduplicated) 878 26840.25000 125962.0000 4.6930
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Total 29705.000000 238210.2600 8.0192
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Number of Children (Unduplicated) With at Least One Service 1453
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Center 54
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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 241 179.250000 7460.6400 0.0000
S 4 3.250000 24.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2896 19288.250000 48900.9800 48490.5800
8982 10199.750000 180541.2400 0.0000
Other 43 34.500000 1283.4000 0.0000
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Total 12166 29705.000000 238210.2600 48490.5800