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:TPIN
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 9 11.750000 437.1000 37.2000
Subtotal (Total Children Is Unduplicated) 9 11.750000 437.1000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 21.500000 1761.0000 81.9070
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 11 19.000000 1425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.000000 825.0000 91.6667
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.500000 787.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 15.500000 1350.0000 87.0968
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 23.500000 1304.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 12 22.000000 1210.0000 55.0000
Subtotal (Total Children Is Unduplicated) 45 125.000000 8962.7500 71.7020
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EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 36.500000 1825.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 12.500000 625.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 46.500000 3786.3400 81.4267
OCCT-97530GT-OT SESSION BY LICENSED OT 6 23.000000 2711.5600 117.8939
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.500000 107.9400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 32 228.890000 20848.8600 91.0868
PHY-97110GT-PT SESSION BY LICENSED PT 5 3.750000 269.8500 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 5.000000 695.8800 139.1760
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 162.050000 12123.4600 74.8131
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 29.500000 3197.2900 108.3827
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 287.8400 71.9600
Subtotal (Total Children Is Unduplicated) 97 554.190000 46529.0200 83.9586
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Total 690.940000 55928.8700 80.9461
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Number of Children (Unduplicated) With at Least One Service 134
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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 135 116.290000 16641.7600 11374.4800
D 508 503.150000 35241.5000 31.5700
S 0 0.000000 0.0000 0.0000
H 1 1.000000 71.9600 0.0000
T 0 0.000000 0.0000 0.0000
69 70.500000 3973.6500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 713 690.940000 55928.8700 11406.0500