CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 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 592 1383.750000 51475.5000 37.2000
Subtotal (Total Children Is Unduplicated) 592 1383.750000 51475.5000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 242.9400 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 8 13.000000 778.9600 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 8 15.000000 1214.7000 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 13.000000 778.9600 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.000000 728.8200 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 242.9400 80.9800
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 4.000000 232.4400 58.1100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 30 72.000000 5122.9100 71.1515
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 28 156.500000 8451.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 5 6.750000 364.5000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 40.000000 3252.8000 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 4 16.000000 1301.1200 81.3200
PHY-97110-PT SESSION BY LICENSED PT 8 37.750000 3069.8300 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 2 9.000000 731.8800 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 1 9.000000 731.8800 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 16.000000 1301.1200 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 406.6000 81.3200
Subtotal (Total Children Is Unduplicated) 50 297.000000 19692.0500 66.3032
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Total 1752.750000 76290.4600 43.5262
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Number of Children (Unduplicated) With at Least One Service 609
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Center 01
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 1 0.250000 9.3000 0.0000
P 0 0.000000 0.0000 0.0000
D 67 68.000000 3893.9900 0.0000
S 778 653.750000 33684.0300 0.0000
H 1425 1010.750000 37870.9000 37870.9000
T 2 2.000000 162.6400 162.6400
15 14.500000 539.4000 0.0000
Other 8 3.500000 130.2000 0.0000
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Total 2296 1752.750000 76290.4600 38033.5400