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: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 669 574.000000 21352.8000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 502 2117.000000 78752.4000 37.2000
Subtotal (Total Children Is Unduplicated) 941 2691.000000 100105.2000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 4 8.250000 412.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 58.500000 4387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 26.000000 1950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 92.500000 5133.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 565.5100 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 86 231.750000 14621.4100 63.0913
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.750000 37.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 109 110.000000 5500.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 16 16.000000 800.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 8 8.000000 400.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 154 157.000000 7850.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 45 45.000000 2250.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 6.000000 300.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 404 2771.000000 138550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 15 65.000000 3250.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 660 4581.000000 68247.0000 14.8978
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 612 4097.000000 49164.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 45.000000 3238.2000 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 2 10.000000 576.0000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 4 18.000000 1295.2800 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 6.000000 431.7600 71.9600
PHY-97110HM-PT SESSION BY PT ASST 4 33.000000 1899.4800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 40.000000 2878.4000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 13.000000 935.4800 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 19.500000 1123.2000 57.6000
TRAV-TRAVS-Travel by mile 3 1251.000000 556.6700 0.4450
Subtotal (Total Children Is Unduplicated) 1170 13297.25000 289532.9700 21.7739
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Total 16220.000000 404259.5800 24.9235
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Number of Children (Unduplicated) With at Least One Service 1587
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 148 173.000000 5546.9000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4969 6794.250000 139879.0000 139879.0000
7815 9247.750000 258634.8800 200.0000
Other 2 5.000000 198.8000 0.0000
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Total 12934 16220.000000 404259.5800 140079.0000