CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2023 ending 09/30/2023 Date of Report:10/10/2023 Page: 1
List order: No List
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.500000 18.6000 37.2000
Subtotal (Total Children Is Unduplicated) 1 0.500000 18.6000 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.6800 14.6800
EXIT-EXIT-COS Exit 3 5.000000 250.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 27 44.500000 3337.5000 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 26 44.000000 2442.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 64 119.000000 7784.1800 65.4133
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 0.750000 37.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 2 2.250000 112.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 31.500000 1575.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 188 742.000000 36800.0000 49.5957
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 96 196.000000 9800.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 208 818.000000 12270.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 42 129.000000 1548.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 47 164.000000 11801.4400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 10 12.000000 863.5200 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 8 19.000000 1367.2400 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
TRAV-TRAVS-Travel by mile 243 12916.00000 5745.7700 0.4449
Subtotal (Total Children Is Unduplicated) 298 15034.50000 82164.8900 5.4651
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Total 15154.000000 89967.6700 5.9369
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Number of Children (Unduplicated) With at Least One Service 352
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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 1484 9571.500000 25656.9600 25656.9600
1630 5582.500000 64310.7100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3114 15154.000000 89967.6700 25656.9600