CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 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 1 0.500000 18.6000 37.2000
Subtotal (Total Children Is Unduplicated) 1 0.500000 18.6000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SCREEN-T1023-SCREENING 5 5.000000 269.9000 53.9800
Subtotal (Total Children Is Unduplicated) 8 10.000000 651.9300 65.1930
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 67 343.250000 18535.5000 54.0000
OCCT-97530TLGO-OT SESSION BY LICENSED OT 6 21.000000 1707.7200 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 9 36.000000 2927.5200 81.3200
PHY-97110TLHM-PT SESSION BY PT ASST 5 17.000000 1107.0400 65.1200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 6 24.000000 1951.6800 81.3200
Subtotal (Total Children Is Unduplicated) 83 441.250000 26229.4600 59.4435
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Total 451.750000 26899.9900 59.5462
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Number of Children (Unduplicated) With at Least One Service 89
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Center 52
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
452 451.750000 26899.9900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 452 451.750000 26899.9900 0.0000