CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 1.500000 55.8000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 2.000000 74.4000 37.2000
Subtotal (Total Children Is Unduplicated) 3 3.500000 130.2000 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 8.8100 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 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 5 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 24.000000 1800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 35.500000 2662.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 40 71.500000 3968.2500 55.5000
Subtotal (Total Children Is Unduplicated) 87 169.000000 10944.2300 64.7588
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1960.0000 1960.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 5.000000 250.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 17.000000 850.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 14.250000 712.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 3 4.250000 212.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 186 707.000000 35350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 86 202.500000 10125.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 197 825.000000 12375.0000 15.0000
INTR-T1013-INTERPRETER 5 4.750000 257.1100 54.1284
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 79 173.000000 2076.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 173.000000 12449.0800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 10 14.000000 1007.4400 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 9 32.000000 2302.7200 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 36.000000 2590.5600 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 4 19.000000 1367.2400 71.9600
TRAV-TRAVS-Travel by mile 267 13377.00000 5951.6300 0.4449
Subtotal (Total Children Is Unduplicated) 314 15612.75000 90302.6600 5.7839
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Total 15785.250000 101377.0900 6.4223
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Number of Children (Unduplicated) With at Least One Service 378
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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 1868 12301.250000 36050.7300 36050.7300
1443 3482.500000 65270.5600 0.0000
Other 2 1.500000 55.8000 0.0000
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Total 3313 15785.250000 101377.0900 36050.7300