CMS/EIP Fiscal Report Center: 53
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 612 1850.750000 68829.3000 37.1900
Subtotal (Total Children Is Unduplicated) 612 1850.750000 68829.3000 37.1900
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 16.500000 915.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 33.500000 2512.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 62 105.500000 7912.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 42 75.000000 5625.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 13.500000 1012.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 25 43.500000 3262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 21.000000 1165.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 104 186.000000 10317.5000 55.4704
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 22.500000 1687.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 19.500000 1462.5000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 7.000000 359.8700 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 2 13.000000 668.3300 51.4100
Subtotal (Total Children Is Unduplicated) 176 607.000000 40611.4500 66.9052
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 42.4100 42.4100
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 277 1467.500000 73375.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 138 360.750000 18037.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 26 139.000000 10002.4400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 15 32.500000 2338.7000 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 51 221.000000 15903.1600 71.9600
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 2 12.000000 863.5200 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 19 55.250000 3975.7900 71.9600
PHY-97110-PT SESSION BY LICENSED PT 3 9.000000 647.6400 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 40 257.250000 18547.6900 72.0999
PHY-97110TLGT-PT SESSION BY LICENSED PT 4 3.250000 233.8700 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 116.000000 8347.3600 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 7.750000 557.6900 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 76 326.000000 23458.9600 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 22 44.500000 3202.2200 71.9600
Subtotal (Total Children Is Unduplicated) 528 3054.750000 179630.9100 58.8038
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Total 5512.500000 289071.6600 52.4393
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Number of Children (Unduplicated) With at Least One Service 730
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Center 53
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 5 4.000000 224.4000 0.0000
P 3977 3764.500000 191731.9400 191646.0400
D 0 0.000000 0.0000 0.0000
S 2 1.750000 125.9300 0.0000
H 16 8.500000 350.9600 0.0000
T 0 0.000000 0.0000 0.0000
1653 1714.500000 95395.7200 0.0000
Other 20 19.250000 1242.7100 0.0000
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Total 5673 5512.500000 289071.6600 191646.0400