CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2023 ending 06/30/2024 Date of Report:04/12/2025 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 209 1019.000000 37878.9000 37.1726
Subtotal (Total Children Is Unduplicated) 209 1019.000000 37878.9000 37.1726
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 19.000000 1054.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 26.500000 1987.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 74 118.500000 8850.0000 74.6835
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 19.530000 1464.5700 74.9908
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 45 77.000000 5775.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 43 66.500000 4958.2500 74.5602
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 17.500000 1010.2500 57.7286
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 126 208.500000 11571.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 24.500000 1837.5000 75.0000
Subtotal (Total Children Is Unduplicated) 196 609.030000 40871.8200 67.1097
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 26.000000 1870.9600 71.9600
Subtotal (Total Children Is Unduplicated) 1 26.000000 1870.9600 71.9600
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Total 1654.030000 80621.6800 48.7426
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Number of Children (Unduplicated) With at Least One Service 216
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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 3 4.000000 148.8000 0.0000
P 1316 1462.500000 68036.1000 67877.1000
D 0 0.000000 0.0000 0.0000
S 2 3.030000 227.0700 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
124 184.500000 12209.7100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1445 1654.030000 80621.6800 67877.1000