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
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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 16.000000 1200.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 21.000000 1575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 19 34.000000 2550.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 36 62.500000 3468.7500 55.5000
Subtotal (Total Children Is Unduplicated) 70 159.500000 10529.2500 66.0141
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 177 1075.500000 53775.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 63 136.500000 6825.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 32 169.000000 12161.2400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 5 7.000000 503.7200 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 7 28.000000 2014.8800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 84.000000 6044.6400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 15 19.000000 1367.2400 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 14 38.000000 2734.4800 71.9600
Subtotal (Total Children Is Unduplicated) 260 1557.000000 85426.2000 54.8659
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Total 1718.500000 96029.8500 55.8800
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Number of Children (Unduplicated) With at Least One Service 303
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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 1718.500000 96029.8500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1653 1718.500000 96029.8500 0.0000