CMS/EIP Fiscal Report Center: 53
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 679 2130.000000 79217.4000 37.1913
Subtotal (Total Children Is Unduplicated) 679 2130.000000 79217.4000 37.1913
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 19.500000 1462.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 18.500000 1026.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 42.000000 3150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 85 142.500000 10687.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 50 87.000000 6525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 37 62.500000 4687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 25.000000 1387.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 139 244.500000 13564.2500 55.4775
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 26.500000 1987.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 19.500000 1462.5000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 7.000000 359.8700 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 2 13.000000 668.3300 51.4100
Subtotal (Total Children Is Unduplicated) 226 761.500000 50941.2000 66.8959
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 42.4100 42.4100
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 277 1467.500000 73375.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 138 360.750000 18037.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 145.000000 10434.2000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 15 32.500000 2338.7000 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 51 221.000000 15903.1600 71.9600
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 2 12.000000 863.5200 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 19 55.250000 3975.7900 71.9600
PHY-97110-PT SESSION BY LICENSED PT 3 9.000000 647.6400 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 40 257.250000 18547.6900 72.0999
PHY-97110TLGT-PT SESSION BY LICENSED PT 4 3.250000 233.8700 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 116.000000 8347.3600 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 7.750000 557.6900 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 76 326.000000 23458.9600 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 22 44.500000 3202.2200 71.9600
Subtotal (Total Children Is Unduplicated) 529 3060.750000 180062.6700 58.8296
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Total 5952.250000 310221.2700 52.1183
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Number of Children (Unduplicated) With at Least One Service 800
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Center 53
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 5 4.000000 224.4000 0.0000
P 4319 4154.250000 209559.2900 209473.3900
D 0 0.000000 0.0000 0.0000
S 2 1.750000 125.9300 0.0000
H 16 8.500000 350.9600 0.0000
T 0 0.000000 0.0000 0.0000
1687 1764.500000 98717.9800 0.0000
Other 20 19.250000 1242.7100 0.0000
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Total 6049 5952.250000 310221.2700 209473.3900