CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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 2 1.750000 65.1000 37.2000
Subtotal (Total Children Is Unduplicated) 2 1.750000 65.1000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 34.000000 2570.9300 75.6156
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.000000 773.9200 77.3920
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.000000 683.9700 75.9967
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 9 16.000000 1241.8600 77.6163
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 18.500000 1408.4300 76.1314
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 13.500000 1036.4200 76.7719
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 98.500000 5601.5600 56.8686
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 15 27.000000 1542.7000 57.1370
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 97.000000 7514.2000 77.4660
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 65.000000 5069.3500 77.9900
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 4 23.000000 1229.3300 53.4491
Subtotal (Total Children Is Unduplicated) 177 425.500000 29565.4200 69.4839
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 31 168.000000 8606.0000 51.2262
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 8 21.000000 1054.0000 50.1905
OCCT-97530-OT SESSION BY LICENSED OT 9 37.000000 2802.9200 75.7546
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 4.000000 287.8400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 11 44.000000 3372.1600 76.6400
PHY-97110GT-PT SESSION BY LICENSED PT 2 9.000000 703.8000 78.2000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 66.000000 4936.5600 74.7964
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 369.1600 73.8320
Subtotal (Total Children Is Unduplicated) 68 355.000000 22204.4000 62.5476
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Total 782.250000 51834.9200 66.2639
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Number of Children (Unduplicated) With at Least One Service 237
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Center 01
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 1 1.000000 50.0000 0.0000
H 471 618.000000 40818.2500 0.0000
T 0 0.000000 0.0000 0.0000
142 163.250000 10966.6700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 614 782.250000 51834.9200 0.0000