CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
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 870 731.250000 27286.2000 37.3145
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 105 83.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1118 4161.500000 154752.0000 37.1866
Subtotal (Total Children Is Unduplicated) 1182 4976.500000 182038.2000 36.5796
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Screening, Eval, and Assessment,Class #02
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.000000 111.0000 55.5000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 38.000000 2850.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 22.000000 1260.0000 57.2727
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 135 273.000000 20475.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 32.000000 2400.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 48.000000 3600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 64.000000 4800.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 131.000000 7270.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 18 36.000000 1998.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 359.8700 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 13 14.000000 719.7400 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 6 6.000000 308.4600 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 17 17.000000 925.3800 54.4341
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
Subtotal (Total Children Is Unduplicated) 256 744.000000 50844.8700 68.3399
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.000000 200.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 1 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 48 47.000000 2350.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 13 18.500000 462.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 17 27.250000 1337.5000 49.0826
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 1 2.000000 100.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 29 57.000000 1425.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 42 42.000000 2100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 11 14.500000 362.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 282 1473.250000 73662.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 10 49.000000 2450.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 141 668.000000 10020.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 483 2904.000000 34848.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 99 467.750000 33659.2900 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 1.750000 125.9300 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 94 668.000000 38476.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 67 302.000000 21731.9200 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 2 5.000000 359.8000 71.9600
PHY-97110HM-PT SESSION BY PT ASST 57 261.547775 15054.6900 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.000000 57.5600 57.5600
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 209 1086.334797 78172.6520 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 359.8000 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 16 76.750000 5522.9300 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
TRAV-TRAVS-Travel by mile 70 5636.000000 2507.1700 0.4448
Subtotal (Total Children Is Unduplicated) 679 13821.63257 325536.6320 23.5527
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Total 19542.132572 558419.7020 28.5752
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Number of Children (Unduplicated) With at Least One Service 1226
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Center 55
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 1636 1516.250000 65703.0400 0.0000
P 6772 11888.265846 193239.9100 192305.4100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 26 47.500000 3551.8600 0.0000
T 0 0.000000 0.0000 0.0000
7289 6090.116726 295924.8920 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15723 19542.132572 558419.7020 192305.4100