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
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 2 4.000000 148.8000 37.2000
Subtotal (Total Children Is Unduplicated) 2 4.000000 148.8000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 12.500000 937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 8.000000 600.0000 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 13 24.000000 1332.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 25.500000 1912.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 57 93.000000 6975.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 67 121.000000 9075.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 13.500000 749.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 127 227.500000 12620.7500 55.4758
Subtotal (Total Children Is Unduplicated) 266 562.500000 36936.5000 65.6649
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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 322 3589.500000 179475.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 196 950.000000 47500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 66 551.000000 39628.0000 71.9201
OCCT-97530GT-OT SESSION BY LICENSED OT 33 82.500000 5936.7000 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 25 122.000000 8779.1200 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 5 8.000000 575.6800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 250.000000 17990.0000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 16 27.000000 1942.9200 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 23 95.000000 6836.2000 71.9600
Subtotal (Total Children Is Unduplicated) 483 5676.000000 308688.6200 54.3849
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Total 6242.500000 345773.9200 55.3903
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Number of Children (Unduplicated) With at Least One Service 613
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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
6004 6242.500000 345773.9200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6004 6242.500000 345773.9200 0.0000