CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2024 ending 06/30/2024 Date of Report:04/12/2025 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 709 2362.000000 87615.2500 37.0937
Subtotal (Total Children Is Unduplicated) 709 2362.000000 87615.2500 37.0937
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Screening, Eval, and Assessment,Class #02
AACIS-92597TL-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 103.3600 103.3600
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 17.000000 943.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 75.000000 5625.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 53 92.000000 6862.5000 74.5924
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 46.530000 3489.5700 74.9961
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 58 103.500000 7725.0000 74.6377
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 24.500000 1837.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 32 54.500000 4087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 55.000000 3091.5000 56.2091
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 105 187.500000 10406.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 21.500000 1612.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 25.500000 1912.5000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 4.000000 205.6400 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 7 42.000000 2159.2200 51.4100
Subtotal (Total Children Is Unduplicated) 215 773.030000 51824.0400 67.0401
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 304 1550.500000 77500.0000 49.9839
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 140 254.750000 12725.0000 49.9509
OCCT-97530-OT SESSION BY LICENSED OT 33 180.000000 12952.8000 71.9600
OCCT-97530GO-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 5 7.000000 503.7200 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 41 151.500000 10901.9400 71.9600
OCCT-97530TLGO-OT SESSION BY LICENSED OT 6 15.500000 1115.3800 71.9600
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 3 5.000000 359.8000 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 17 20.750000 1493.1700 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 215.8800 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 47 252.000000 18133.9200 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 7 6.500000 467.7400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 88.200000 6346.7400 71.9585
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 16 20.000000 1439.2000 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 72 308.250000 22181.6700 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 17 27.250000 1960.9100 71.9600
Subtotal (Total Children Is Unduplicated) 544 2891.200000 168369.8300 58.2353
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Total 6026.230000 307809.1200 51.0782
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Number of Children (Unduplicated) With at Least One Service 831
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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 10 11.500000 585.7200 0.0000
P 4328 4220.500000 206168.4900 206025.3700
D 0 0.000000 0.0000 0.0000
S 8 9.230000 679.1700 0.0000
H 6 4.250000 158.1000 0.0000
T 0 0.000000 0.0000 0.0000
1690 1771.500000 99690.1600 0.0000
Other 8 9.250000 527.4800 50.0000
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Total 6050 6026.230000 307809.1200 206075.3700