CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Agency Filter:EXT
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 49 79.750000 2966.7000 37.2000
Subtotal (Total Children Is Unduplicated) 49 79.750000 2966.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 119.8400 59.9200
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 31.500000 1887.4800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 174.3300 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 232.4400 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 232.4400 58.1100
Subtotal (Total Children Is Unduplicated) 30 49.000000 2910.7400 59.4029
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 754 4604.000000 248616.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 23 51.000000 2754.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 93.000000 7562.7600 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 13 67.000000 4363.0400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 4 19.000000 1545.0800 81.3200
PHY-97110HM-PT SESSION BY PT ASST 11 63.500000 4135.1200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 95.250000 7745.7300 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 13 42.000000 2735.0400 65.1200
Subtotal (Total Children Is Unduplicated) 789 5034.750000 279456.7700 55.5056
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Total 5163.500000 285334.2100 55.2598
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Number of Children (Unduplicated) With at Least One Service 835
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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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 68 79.750000 2966.7000 2966.7000
T 0 0.000000 0.0000 0.0000
5090 5083.750000 282367.5100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5158 5163.500000 285334.2100 2966.7000