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: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 612 1848.750000 68754.9000 37.1899
Subtotal (Total Children Is Unduplicated) 612 1848.750000 68754.9000 37.1899
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 11.500000 862.5000 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 1 2.000000 150.0000 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 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 27.500000 2062.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 37 66.000000 4950.0000 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 26 44.500000 3337.5000 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 42.000000 3150.0000 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 77 136.000000 7548.0000 55.5000
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) 149 459.000000 30725.9500 66.9411
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 42.4100 42.4100
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 121 487.500000 24375.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 59 106.750000 5337.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 40 192.000000 13816.3200 71.9600
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 2 12.000000 863.5200 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 17 51.250000 3687.9500 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 5 13.000000 935.4800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 0.750000 53.9700 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 69 310.000000 22307.6000 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 22 44.500000 3202.2200 71.9600
Subtotal (Total Children Is Unduplicated) 287 1490.250000 94195.0900 63.2076
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Total 3798.000000 193675.9400 50.9942
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Number of Children (Unduplicated) With at Least One Service 670
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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
0 0.000000 0.0000 0.0000
Other 20 19.250000 1242.7100 0.0000
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Total 4020 3798.000000 193675.9400 191646.0400