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
Payclass Filters:GR
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-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-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-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 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 4 4.000000 205.6400 51.4100
Subtotal (Total Children Is Unduplicated) 57 103.927467 6768.5800 65.1279
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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 100 533.000000 26650.0000 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 74 327.071427 23536.0600 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) 591 10684.86855 133195.1900 12.4658
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Total 10788.796017 139963.7700 12.9731
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Number of Children (Unduplicated) With at Least One Service 608
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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 5445 10665.515846 137420.3700 137420.3700
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
104 123.280171 2543.4000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5549 10788.796017 139963.7700 137420.3700