CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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 931 3552.000000 132134.4000 37.2000
Subtotal (Total Children Is Unduplicated) 931 3552.000000 132134.4000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 404.9000 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 12.000000 971.7600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 9 15.000000 940.9200 62.7280
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 84.000000 6802.3200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 15.500000 1255.1900 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 46 77.000000 6235.4600 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 9.500000 769.3100 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 46.000000 3725.0800 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 12.000000 971.7600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 124 213.000000 12762.9600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 34.500000 2067.2400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 283.4300 80.9800
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 116.2200 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 232.4400 58.1100
Subtotal (Total Children Is Unduplicated) 165 542.000000 38153.4600 70.3938
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 831 8394.000000 453276.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 20 85.000000 4590.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 111.500000 8992.3000 80.6484
OCCT-97530HM-OT SESSION BY OT ASST 4 21.500000 1400.0800 65.1200
OCCT-97530TLHM-OT SESSION BY OT ASST 1 4.000000 260.4800 65.1200
PHY-97110-PT SESSION BY LICENSED PT 1 8.500000 691.2200 81.3200
PHY-97110HM-PT SESSION BY PT ASST 6 50.750000 3304.8400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 51.500000 4167.8000 80.9282
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 25.000000 1628.0000 65.1200
Subtotal (Total Children Is Unduplicated) 855 8751.750000 478310.7200 54.6532
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Total 12845.750000 648598.5800 50.4913
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Number of Children (Unduplicated) With at Least One Service 1097
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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 2 2.000000 135.3200 0.0000
S 0 0.000000 0.0000 0.0000
H 2840 4056.500000 168060.7700 168042.1700
T 0 0.000000 0.0000 0.0000
8811 8787.250000 480402.4900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11653 12845.750000 648598.5800 168042.1700