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
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 848 2939.250000 109228.5000 37.1620
Subtotal (Total Children Is Unduplicated) 848 2939.250000 109228.5000 37.1620
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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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 750.0000 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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 14 25.500000 1415.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 23 44.500000 3337.5000 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 53 100.500000 7537.5000 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 28 54.500000 4087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 22.500000 1248.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 94 183.000000 10156.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 30.000000 2250.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 48 91.000000 6825.0000 75.0000
Subtotal (Total Children Is Unduplicated) 204 654.000000 44446.2200 67.9606
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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 6 14.000000 350.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 314 1123.250000 56162.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 147 359.000000 17950.0000 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 11 21.000000 1511.1600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 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 20 83.500000 6008.6600 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) 516 2066.370000 115456.0700 55.8739
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Total 5659.620000 269130.7900 47.5528
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Number of Children (Unduplicated) With at Least One Service 904
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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 1 0.500000 18.6000 0.0000
S 20 19.640000 1355.0300 0.0000
H 8 7.480000 503.9600 0.0000
T 0 0.000000 0.0000 0.0000
1318 1409.750000 74568.7600 0.0000
Other 108 90.250000 4324.3800 0.0000
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Total 5850 5659.620000 269130.7900 159555.1100