CMS/EIP Fiscal Report Center: 55
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 703 2981.000000 110911.8000 37.2062
Subtotal (Total Children Is Unduplicated) 703 2981.000000 110911.8000 37.2062
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 56.000000 4200.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.000000 666.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 127 254.000000 19050.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 32.000000 2400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 104.000000 5772.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 9 18.000000 1007.8400 55.9911
Subtotal (Total Children Is Unduplicated) 183 486.000000 33845.8400 69.6416
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 32 242.000000 12104.0000 50.0165
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 19.000000 1367.2400 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 11 66.000000 4749.3600 71.9600
Subtotal (Total Children Is Unduplicated) 46 327.000000 18220.6000 55.7205
-----------------------------------------------------------------------------------------------------------------------
Total 3794.000000 162978.2400 42.9568
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 708
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 428 429.000000 20180.6000 18.6000
P 3312 3365.000000 142797.6400 142770.2000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3740 3794.000000 162978.2400 142788.8000