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:TPIN
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 4 9.000000 334.8000 37.2000
Subtotal (Total Children Is Unduplicated) 4 9.000000 334.8000 37.2000
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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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 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 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 11.500000 862.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 13 25.000000 1875.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.500000 712.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 23.500000 1762.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 40.000000 2220.0000 55.5000
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 7 14.000000 1050.0000 75.0000
Subtotal (Total Children Is Unduplicated) 60 168.000000 11711.8600 69.7135
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 2 2.000000 84.8200 42.4100
ASST-ASST-ASSISTIVE TECHNOLOGY 6 14.000000 1007.4400 71.9600
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 105 340.000000 17000.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 49 94.500000 4725.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 33 138.520000 9969.2800 71.9700
OCCT-97530GT-OT SESSION BY LICENSED OT 14 20.000000 1439.2000 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 2 4.000000 287.8400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 19 64.500000 4809.4600 74.5653
PHY-97110GT-PT SESSION BY LICENSED PT 2 1.750000 125.9300 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 184.860000 13303.8600 71.9672
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 5.000000 359.8000 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 199 873.130000 53378.5100 61.1347
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Total 1050.130000 65425.1700 62.3020
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Number of Children (Unduplicated) With at Least One Service 242
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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 11 8.080000 753.8800 610.1400
D 60 62.300000 4148.3800 0.0000
S 0 0.000000 0.0000 0.0000
H 118 126.000000 8659.0000 0.0000
T 346 362.140000 19595.5500 19595.5500
461 487.610000 31980.5200 0.0000
Other 4 4.000000 287.8400 0.0000
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Total 1000 1050.130000 65425.1700 20205.6900