CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
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 1022 867.000000 32336.1000 37.2965
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 113 91.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1284 4994.000000 185748.9000 37.1944
Subtotal (Total Children Is Unduplicated) 1360 5952.500000 218085.0000 36.6375
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Screening, Eval, and Assessment,Class #02
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.000000 111.0000 55.5000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 30 62.000000 4650.0000 75.0000
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 4 8.000000 600.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 14.000000 1050.0000 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 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 32.000000 1815.0000 56.7188
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 234 472.000000 35400.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 29 58.000000 4350.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 68.000000 5100.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 88.000000 6600.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 14.000000 1050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 124 246.000000 13653.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 33 66.000000 3663.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 359.8700 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 13 14.000000 719.7400 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 6 6.000000 308.4600 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 17 17.000000 925.3800 54.4341
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
Subtotal (Total Children Is Unduplicated) 400 1218.000000 83333.3700 68.4182
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.000000 200.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 1 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 48 47.000000 2350.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 13 18.500000 462.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 17 27.250000 1337.5000 49.0826
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 1 2.000000 100.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 29 57.000000 1425.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 42 42.000000 2100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 11 14.500000 362.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 282 1473.250000 73662.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 10 49.000000 2450.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 141 668.000000 10020.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 484 2907.000000 34884.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 99 467.750000 33659.2900 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 1.750000 125.9300 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 94 668.000000 38476.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 68 305.000000 21947.8000 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 2 5.000000 359.8000 71.9600
PHY-97110HM-PT SESSION BY PT ASST 57 261.547775 15054.6900 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.000000 57.5600 57.5600
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 209 1086.334797 78172.6520 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 359.8000 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 16 76.750000 5522.9300 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
TRAV-TRAVS-Travel by mile 70 5636.000000 2507.1700 0.4448
Subtotal (Total Children Is Unduplicated) 680 13827.63257 325788.5120 23.5607
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Total 20998.132572 627206.8820 29.8697
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Number of Children (Unduplicated) With at Least One Service 1404
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Center 55
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 1808 1833.500000 82221.6400 0.0000
P 6881 12091.193313 203709.7500 201933.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 41 77.500000 5801.8600 0.0000
T 0 0.000000 0.0000 0.0000
8103 6995.939259 335473.6320 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16833 20998.132572 627206.8820 201933.7500