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:TPIN
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
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
Subtotal (Total Children Is Unduplicated) 7 13.000000 867.7500 66.7500
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1960.0000 1960.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 54.000000 2700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 6.000000 300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 83.000000 5972.6800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 5 6.000000 431.7600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 8.000000 575.6800 71.9600
Subtotal (Total Children Is Unduplicated) 35 158.000000 11940.1200 75.5704
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Total 171.000000 12807.8700 74.8998
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Number of Children (Unduplicated) With at Least One Service 41
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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 54 55.500000 4726.2100 4726.2100
111 115.500000 8081.6600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 165 171.000000 12807.8700 4726.2100