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
Agency Filter:EXT
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 1 2.000000 74.4000 37.2000
Subtotal (Total Children Is Unduplicated) 1 2.000000 74.4000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 25 39.500000 2962.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 16 30.500000 2287.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 28 50.000000 2769.5000 55.3900
Subtotal (Total Children Is Unduplicated) 71 148.000000 9885.5000 66.7939
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 156 980.000000 49000.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 79 254.000000 12700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 138.000000 9930.4800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 15 32.500000 2338.7000 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 11 29.000000 2086.8400 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 4.000000 287.8400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 103.000000 7411.8800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 7.000000 503.7200 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 7 16.000000 1151.3600 71.9600
Subtotal (Total Children Is Unduplicated) 246 1564.500000 85435.8200 54.6090
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Total 1714.500000 95395.7200 55.6405
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Number of Children (Unduplicated) With at Least One Service 286
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
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
1653 1714.500000 95395.7200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1653 1714.500000 95395.7200 0.0000