CMS/EIP Fiscal Report Center: 55
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: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 633 2728.750000 101444.4000 37.1761
Subtotal (Total Children Is Unduplicated) 633 2728.750000 101444.4000 37.1761
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 18.000000 1457.6400 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 323.9200 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 9 18.000000 1078.5600 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 104 209.000000 16924.8200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 14 28.000000 2267.4400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 48.000000 3887.0400 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 485.8800 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 26.000000 2105.4800 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 485.8800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 77.000000 4613.8400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 11 22.000000 1318.2400 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 116.2200 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 6.000000 348.6600 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 174.3300 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 156 487.000000 36500.2100 74.9491
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 194 718.000000 38772.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 30.500000 1647.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 31 143.500000 11669.4200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 47 213.750000 13919.4000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 21 105.000000 8538.6000 81.3200
PHY-97110HM-PT SESSION BY PT ASST 25 107.750000 7032.9600 65.2711
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 80 298.000000 24233.3600 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 162.6400 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 18 61.000000 4960.5200 81.3200
Subtotal (Total Children Is Unduplicated) 375 1679.500000 110935.9000 66.0529
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Total 4895.250000 248880.5100 50.8412
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Number of Children (Unduplicated) With at Least One Service 657
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Center 55
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 3120 3061.000000 130115.1000 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
1820 1834.250000 118765.4100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4940 4895.250000 248880.5100 0.0000