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
Agency Filter:EXT
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-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 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 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-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 7 16.000000 1200.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 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 29 58.000000 3219.0000 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 13 13.000000 719.7400 55.3646
Subtotal (Total Children Is Unduplicated) 143 278.000000 18443.0900 66.3421
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.000000 150.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 1 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 31 30.000000 1500.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 11 16.500000 412.5000 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 26 26.000000 1300.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 6 6.500000 162.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 247 1266.250000 63312.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 37.000000 1850.0000 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 199 1059.834797 76265.7120 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 359.8000 71.9600
TRAV-TRAVS-Travel by mile 70 5636.000000 2507.1700 0.4448
Subtotal (Total Children Is Unduplicated) 626 13454.38257 305134.8020 22.6792
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Total 13732.382572 323577.8920 23.5631
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Number of Children (Unduplicated) With at Least One Service 689
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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 0 0.000000 0.0000 0.0000
P 5680 10905.265846 153679.2100 153679.2100
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
2770 2827.116726 169898.6820 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8450 13732.382572 323577.8920 153679.2100