CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2024 ending 03/31/2024 Date of Report:04/04/2025 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1058 4244.750000 157904.7000 37.2000
Subtotal (Total Children Is Unduplicated) 1058 4244.750000 157904.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 9.000000 675.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 138.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 18.000000 999.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 36.500000 2737.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 106 146.500000 10987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 10.500000 787.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 67 94.000000 7050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 37 46.500000 2580.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 171 240.000000 13320.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 35.500000 2662.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 91 144.500000 10837.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 308.4600 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 329.0100 54.8350
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 281 809.000000 54237.2500 67.0423
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 866 8265.000000 413250.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 19 104.000000 5200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 94.000000 6764.2400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 10 69.500000 4003.2000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 2 14.000000 1007.4400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 8 47.000000 3382.1200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 14 123.000000 7079.8800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 18.000000 1295.2800 71.9600
Subtotal (Total Children Is Unduplicated) 894 8734.500000 441982.1600 50.6019
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Total 13788.250000 654124.1100 47.4407
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Number of Children (Unduplicated) With at Least One Service 1359
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Center 04
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 425 726.500000 29611.2000 0.0000
P 2308 3875.750000 153956.4800 150647.7200
D 45 62.500000 2773.8000 0.0000
S 0 0.000000 0.0000 0.0000
H 8764 8719.500000 440626.2000 0.0000
T 0 0.000000 0.0000 0.0000
314 402.500000 27083.2500 0.0000
Other 2 1.500000 73.1800 0.0000
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Total 11858 13788.250000 654124.1100 150647.7200