CMS/EIP Fiscal Report Center: 57
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: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 821 3007.500000 111879.0000 37.2000
Subtotal (Total Children Is Unduplicated) 821 3007.500000 111879.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 16.000000 1200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 23.500000 1304.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 125 199.000000 14925.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 40 56.500000 4237.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 169 280.000000 15540.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 12.000000 863.5200 71.9600
Subtotal (Total Children Is Unduplicated) 198 621.500000 40327.5100 64.8874
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 734 5031.000000 251550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 27 112.000000 5404.0000 48.2500
OCCT-97530-OT SESSION BY LICENSED OT 27 169.750000 12215.2100 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 6 17.000000 979.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 3 14.000000 1007.4400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 15 129.750000 7468.4100 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 111.500000 8023.5400 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 16 72.750000 4132.8000 56.8082
Subtotal (Total Children Is Unduplicated) 784 5661.750000 291068.4400 51.4096
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Total 9290.750000 443274.9500 47.7114
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Number of Children (Unduplicated) With at Least One Service 1081
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Center 57
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 1534 2266.500000 98801.7000 0.0000
P 11 17.500000 1127.2500 1127.2500
D 0 0.000000 0.0000 0.0000
S 4 5.500000 354.0000 0.0000
H 250 364.000000 13540.8000 13540.8000
T 1 1.500000 83.2500 83.2500
4763 6416.000000 321193.2500 0.0000
Other 214 219.750000 8174.7000 0.0000
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Total 6777 9290.750000 443274.9500 14751.3000