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:EIP DEI DEIP
Payclass Filters:MED
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 598 2071.000000 76985.4000 37.1731
Subtotal (Total Children Is Unduplicated) 598 2071.000000 76985.4000 37.1731
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 20.000000 1500.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 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 5 10.000000 594.0000 59.4000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 70 141.000000 10575.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 41.000000 2275.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 16.000000 888.0000 55.5000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
Subtotal (Total Children Is Unduplicated) 105 257.000000 17889.5500 69.6091
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 15 91.000000 4550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 5.000000 250.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.500000 179.9000 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
Subtotal (Total Children Is Unduplicated) 35 176.250000 10574.7900 59.9988
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Total 2504.250000 105449.7400 42.1083
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Number of Children (Unduplicated) With at Least One Service 600
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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 1634 1515.750000 65684.4400 0.0000
P 1091 982.500000 39542.1000 38607.6000
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
2 6.000000 223.2000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2727 2504.250000 105449.7400 38607.6000