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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 881 3382.500000 125829.0000 37.2000
Subtotal (Total Children Is Unduplicated) 881 3382.500000 125829.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 21.000000 1575.0000 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 6 9.500000 712.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 32.000000 1776.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 151 235.000000 17625.0000 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 5 8.500000 637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 63 87.000000 6525.0000 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 214 345.500000 19175.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 8.000000 600.0000 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) 254 781.500000 50884.5100 65.1113
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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 9825.750000 467781.9500 47.6078
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Number of Children (Unduplicated) With at Least One Service 1144
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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 1739 2640.500000 116664.0000 0.0000
P 16 23.500000 1538.2500 1538.2500
D 0 0.000000 0.0000 0.0000
S 6 9.000000 587.2500 0.0000
H 270 401.750000 14945.1000 14945.1000
T 1 1.500000 83.2500 83.2500
4822 6529.750000 325789.4000 0.0000
Other 214 219.750000 8174.7000 0.0000
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Total 7068 9825.750000 467781.9500 16566.6000