CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 4 8.000000 400.0000 50.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
Subtotal (Total Children Is Unduplicated) 9 18.500000 1060.7500 57.3378
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 329.6000 82.4000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 4 2.000000 100.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 24 33.000000 1650.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 33 134.000000 6700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 19 39.000000 1950.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 303 1338.000000 13380.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 3.000000 215.8800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 8 4.750000 175.7500 37.0000
TRAV-TRAVS-Travel by mile 298 18157.00000 8077.1200 0.4448
Subtotal (Total Children Is Unduplicated) 318 19720.75000 32919.2300 1.6693
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Total 19739.250000 33979.9800 1.7214
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Number of Children (Unduplicated) With at Least One Service 323
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Center 53
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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1494 10680.750000 18376.7500 18376.7500
1368 9058.500000 15603.2300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2862 19739.250000 33979.9800 18376.7500