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: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 646 2083.000000 77264.3500 37.0928
Subtotal (Total Children Is Unduplicated) 646 2083.000000 77264.3500 37.0928
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Screening, Eval, and Assessment,Class #02
AACIS-92597TL-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 103.3600 103.3600
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 42.500000 3187.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 33 58.500000 4387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 26.000000 1950.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 24 42.500000 3150.0000 74.1176
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 19.500000 1462.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 21 37.000000 2775.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 34.000000 1887.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 50 89.000000 4939.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 17.500000 1312.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 20.500000 1537.5000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 4.000000 205.6400 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 7 42.000000 2159.2200 51.4100
Subtotal (Total Children Is Unduplicated) 146 459.000000 30776.2200 67.0506
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 128 475.000000 23725.0000 49.9474
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 77 118.250000 5900.0000 49.8943
OCCT-97530GO-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 34 123.500000 8887.0600 71.9600
OCCT-97530TLGO-OT SESSION BY LICENSED OT 6 15.500000 1115.3800 71.9600
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 3 5.000000 359.8000 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 17 20.750000 1493.1700 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 215.8800 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 47 252.000000 18133.9200 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 7 6.500000 467.7400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.200000 302.1000 71.9286
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 58 270.250000 19447.1900 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 17 27.250000 1960.9100 71.9600
Subtotal (Total Children Is Unduplicated) 289 1323.200000 82152.0700 62.0859
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Total 3865.200000 190192.6400 49.2064
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Number of Children (Unduplicated) With at Least One Service 702
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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 7 7.500000 436.9200 0.0000
P 3972 3838.000000 188618.0400 188587.4200
D 0 0.000000 0.0000 0.0000
S 6 6.200000 452.1000 0.0000
H 6 4.250000 158.1000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 8 9.250000 527.4800 50.0000
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Total 3999 3865.200000 190192.6400 188637.4200