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
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 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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.000000 825.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 28.000000 1554.0000 55.5000
Subtotal (Total Children Is Unduplicated) 36 62.000000 3913.7300 63.1247
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EI Services,Class #03
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 44 187.000000 9350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 13 29.000000 1450.0000 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 2 5.000000 359.8000 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 8.000000 575.6800 71.9600
TRAV-TRAVS-Travel by mile 267 13377.00000 5951.6300 0.4449
Subtotal (Total Children Is Unduplicated) 285 14654.25000 34670.2200 2.3659
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Total 14719.750000 38714.1500 2.6301
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Number of Children (Unduplicated) With at Least One Service 311
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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 1814 12245.750000 31324.5200 31324.5200
479 2472.500000 7333.8300 0.0000
Other 2 1.500000 55.8000 0.0000
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Total 2295 14719.750000 38714.1500 31324.5200