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
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 870 731.250000 27286.2000 37.3145
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 105 83.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 646 2090.500000 77766.6000 37.2000
Subtotal (Total Children Is Unduplicated) 1058 2905.500000 105052.8000 36.1565
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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 3 5.112800 383.4600 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.927467 144.5600 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 65.646533 4923.4900 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 30.000000 2250.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 52.000000 2886.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 20.000000 1110.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 359.8700 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 94 235.686800 15534.9400 65.9135
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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 120 649.000000 32450.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 350.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 141 668.000000 10020.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 483 2899.000000 34788.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 109.500000 7879.6200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 0.750000 53.9700 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 26 169.575869 9767.5700 57.6000
PHY-97110-PT SESSION BY LICENSED PT 26 109.571151 7884.7400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 16 59.150103 3404.6800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 77 338.071427 24327.6200 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 215.8800 71.9600
TRAV-TRAVS-Travel by mile 70 5636.000000 2507.1700 0.4448
Subtotal (Total Children Is Unduplicated) 622 10862.86855 142086.7500 13.0800
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Total 14004.055350 262674.4900 18.7570
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Number of Children (Unduplicated) With at Least One Service 1173
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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 2 0.500000 18.6000 0.0000
P 5446 10666.015846 137438.9700 137438.9700
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 0 0.000000 0.0000 0.0000
4590 3337.539504 125216.9200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10038 14004.055350 262674.4900 137438.9700