CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2024 ending 03/31/2024 Date of Report:04/04/2025 Page: 1
List order: No List
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 1003 3918.250000 145758.9000 37.2000
Subtotal (Total Children Is Unduplicated) 1003 3918.250000 145758.9000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 7.500000 562.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 55.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 15.500000 860.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 25.500000 1912.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 88 123.000000 9225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 62 88.500000 6637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 39.000000 2164.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 140 200.000000 11100.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 30.500000 2287.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 74 123.000000 9225.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 308.4600 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 329.0100 54.8350
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 235 686.000000 46016.5000 67.0794
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 866 8265.000000 413250.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 19 104.000000 5200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 94.000000 6764.2400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 10 69.500000 4003.2000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 2 14.000000 1007.4400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 8 47.000000 3382.1200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 14 123.000000 7079.8800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 18.000000 1295.2800 71.9600
Subtotal (Total Children Is Unduplicated) 894 8734.500000 441982.1600 50.6019
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Total 13338.750000 633757.5600 47.5125
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Number of Children (Unduplicated) With at Least One Service 1301
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Center 04
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 382 644.500000 26064.4500 0.0000
P 2165 3593.250000 142680.3800 139577.9400
D 38 52.500000 2289.6000 0.0000
S 0 0.000000 0.0000 0.0000
H 8764 8719.500000 440626.2000 0.0000
T 0 0.000000 0.0000 0.0000
251 327.500000 22023.7500 0.0000
Other 2 1.500000 73.1800 0.0000
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Total 11602 13338.750000 633757.5600 139577.9400