CMS/EIP Fiscal Report Center: 55
Services beginning 07/01/2024 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 697 6689.000000 248840.1000 37.2014
Subtotal (Total Children Is Unduplicated) 697 6689.000000 248840.1000 37.2014
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 72 142.000000 11200.1600 78.8744
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 30.000000 2381.5600 79.3853
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.000000 761.9600 76.1960
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 311.9600 77.9900
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 28.000000 2195.6800 78.4171
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 311.9600 77.9900
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 36 67.500000 3956.2000 58.6104
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 22.000000 1300.5600 59.1164
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 102 204.000000 15694.6800 76.9347
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 32.000000 2471.7600 77.2425
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 42.000000 3197.8400 76.1390
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 50.000000 3845.6800 76.9136
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 14.000000 1085.8800 77.5629
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 67 134.000000 7666.8400 57.2152
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 12 24.000000 1376.2000 57.3417
OCTF-97168-OT RE-EVAL EST PLAN CARE 27 30.000000 1716.5000 57.2167
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 174.3300 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 160.9300 53.6433
OCTH-97167-OT EVAL HIGH COMPLEXITY 22 22.000000 1191.3200 54.1509
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 16 17.000000 967.7700 56.9276
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 8 8.000000 431.3800 53.9225
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 22 22.000000 1204.7200 54.7600
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 315 921.500000 64174.6000 69.6415
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 265 4914.000000 258805.0000 52.6669
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 24 89.250000 4739.5000 53.1036
OCCT-97530-OT SESSION BY LICENSED OT 60 762.500000 59986.6000 78.6710
OCCT-97530HM-OT SESSION BY OT ASST 82 1602.500000 100722.6400 62.8534
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 1 2.000000 130.2400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 41 611.000000 47898.7600 78.3940
PHY-97110HM-PT SESSION BY PT ASST 42 618.250000 38822.3100 62.7939
PHY-97110HMGT-PT SESSION BY PT ASST 1 1.000000 65.1200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 137 1902.000000 147835.5000 77.7263
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 19 241.750000 19041.3500 78.7646
Subtotal (Total Children Is Unduplicated) 517 10745.25000 678104.6200 63.1074
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Total 18355.750000 991119.3200 53.9950
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Number of Children (Unduplicated) With at Least One Service 705
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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 4548 4171.000000 178612.3100 18.6000
P 4320 3866.250000 157259.9600 156870.5600
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
10304 10318.500000 655247.0500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 19172 18355.750000 991119.3200 156889.1600