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:EIP DEI DEIP
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 9 11.000000 409.2000 37.2000
Subtotal (Total Children Is Unduplicated) 9 11.000000 409.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 13.000000 975.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 25.500000 1912.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 27.500000 1526.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 41 92.000000 6245.8000 67.8891
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 2.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 36.500000 1825.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 7.000000 337.2000 48.1714
OCCT-97530-OT SESSION BY LICENSED OT 15 49.000000 3526.0400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 6 17.500000 1259.3000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 26 106.750000 7849.7700 73.5341
PHY-97110GT-PT SESSION BY LICENSED PT 5 4.250000 305.8300 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 133.350000 9595.9500 71.9606
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 12.270000 883.3300 71.9910
Subtotal (Total Children Is Unduplicated) 86 370.120000 25654.3800 69.3137
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Total 473.120000 32309.3800 68.2900
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Number of Children (Unduplicated) With at Least One Service 121
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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 11 6.680000 650.0800 485.6800
D 118 120.940000 7905.8700 0.0000
S 0 0.000000 0.0000 0.0000
H 89 90.500000 6468.9700 0.0000
T 0 0.000000 0.0000 0.0000
242 255.000000 17284.4600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 460 473.120000 32309.3800 485.6800