CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2024 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 63 277.000000 10276.5000 37.0993
Subtotal (Total Children Is Unduplicated) 63 277.000000 10276.5000 37.0993
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 16.500000 1237.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 12.500000 900.0000 72.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 12.530000 939.5700 74.9856
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 27.000000 2025.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 15.500000 1162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 13.500000 788.2500 58.3889
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 22 36.000000 1998.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
Subtotal (Total Children Is Unduplicated) 47 154.530000 10518.5700 68.0681
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 11.000000 791.5600 71.9600
Subtotal (Total Children Is Unduplicated) 1 11.000000 791.5600 71.9600
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Total 442.530000 21586.6300 48.7800
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Number of Children (Unduplicated) With at Least One Service 65
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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 356 382.500000 17550.4500 17437.9500
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
37 53.000000 3660.3100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 398 442.530000 21586.6300 17437.9500