CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 114 364.000000 13540.8000 37.2000
Subtotal (Total Children Is Unduplicated) 114 364.000000 13540.8000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 11.500000 931.2700 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 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 5 9.500000 569.2400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 79 138.500000 11215.7300 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.500000 364.4100 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 29.000000 2348.4200 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 283.4300 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 27.000000 2186.4600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 59 103.000000 6141.8000 59.6291
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 15.000000 1336.1700 89.0780
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 94 348.000000 25848.8400 74.2783
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 13.000000 702.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 3.000000 243.9600 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 40.6600 81.3200
Subtotal (Total Children Is Unduplicated) 1 16.500000 986.6200 59.7952
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Total 728.500000 40376.2600 55.4238
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Number of Children (Unduplicated) With at Least One Service 125
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Center 10
Flag Claims Units Chgs Paid
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R 28 27.750000 1032.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 517 680.000000 38178.3300 0.0000
P 0 0.000000 0.0000 0.0000
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
18 17.500000 1044.7300 0.0000
Other 5 3.250000 120.9000 0.0000
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Total 568 728.500000 40376.2600 0.0000