CMS/EIP Fiscal Report Center: 57
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
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 905 3869.250000 143936.1000 37.2000
Subtotal (Total Children Is Unduplicated) 905 3869.250000 143936.1000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 8 14.500000 804.7500 55.5000
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 82 136.000000 10200.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 12 19.000000 1425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 78 126.000000 9450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 22.000000 1650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 33 54.000000 4050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 13.000000 977.9900 75.2300
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 170 285.000000 15856.5000 55.6368
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 34 54.000000 2997.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 37.500000 2812.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 15 15.000000 777.8500 51.8567
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 616.9200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 7.000000 359.8700 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 25 25.000000 1285.2500 51.4100
Subtotal (Total Children Is Unduplicated) 277 851.000000 55308.0700 64.9919
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 885 8411.750000 421568.5000 50.1166
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 30 122.000000 6308.0000 51.7049
OCCT-97530-OT SESSION BY LICENSED OT 48 409.000000 29431.6400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 33 145.000000 8352.0000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 4 7.500000 539.7000 71.9600
OCCT-97530TLHM-OT SESSION BY OT ASST 1 3.000000 172.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 11 129.000000 9275.6400 71.9042
PHY-97110HM-PT SESSION BY PT ASST 29 287.250000 16664.2700 58.0131
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 51 305.500000 22057.2000 72.2003
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 162.6400 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 40 193.000000 11137.7400 57.7085
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 3.500000 251.8600 71.9600
Subtotal (Total Children Is Unduplicated) 943 10018.50000 525921.9900 52.4951
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Total 14738.750000 725166.1600 49.2013
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Number of Children (Unduplicated) With at Least One Service 1107
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Center 57
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 1 1.000000 50.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3166 4619.000000 193919.0900 192756.5900
T 0 0.000000 0.0000 0.0000
10267 10118.750000 531197.0700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 13434 14738.750000 725166.1600 192756.5900