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
Payclass Filters:GR
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
EXIT-EXIT-COS Exit 3 5.000000 250.0000 50.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 8.000000 600.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 5.000000 277.5000 55.5000
Subtotal (Total Children Is Unduplicated) 12 21.500000 1321.7500 61.4767
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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 29 110.000000 5200.0000 47.2727
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 8 12.000000 600.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 208 807.000000 12105.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 42 129.000000 1548.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 12.000000 863.5200 71.9600
TRAV-TRAVS-Travel by mile 243 12916.00000 5745.7700 0.4449
Subtotal (Total Children Is Unduplicated) 253 14022.50000 27887.2900 1.9888
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Total 14044.500000 29227.6400 2.0811
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Number of Children (Unduplicated) With at Least One Service 263
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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 1360 9447.000000 19792.8200 19792.8200
685 4597.500000 9434.8200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2045 14044.500000 29227.6400 19792.8200