CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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 1826 5294.750000 196843.8000 37.1772
Subtotal (Total Children Is Unduplicated) 1826 5294.750000 196843.8000 37.1772
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 11 18.000000 1007.8400 55.9911
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 40 67.500000 5188.0800 76.8604
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 28.500000 2200.2900 77.2032
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 20.500000 1555.4400 75.8751
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 29.000000 2198.9200 75.8248
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 25.000000 1931.8100 77.2724
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 14 26.000000 2000.8300 76.9550
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 118 191.500000 10875.7700 56.7925
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 44 74.500000 4181.1600 56.1230
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 134 233.000000 17872.6700 76.7067
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 95 174.500000 13293.8100 76.1823
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 5 17.000000 934.2700 54.9571
Subtotal (Total Children Is Unduplicated) 417 911.500000 63717.7300 69.9043
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 102 422.750000 21445.5000 50.7286
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 21 32.500000 1635.0000 50.3077
OCCT-97530-OT SESSION BY LICENSED OT 6 18.000000 1314.0000 73.0000
OCCT-97530TL-OT SESSION BY LICENSED OT 11 55.000000 4107.5600 74.6829
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 11.000000 819.6400 74.5127
PHY-97110-PT SESSION BY LICENSED PT 1 6.000000 469.2000 78.2000
PHY-97110TL-PT SESSION BY LICENSED PT 11 52.000000 4001.6600 76.9550
PHY-97110TLGT-PT SESSION BY LICENSED PT 4 11.000000 829.0000 75.3636
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 23 33.750000 2447.3700 72.5147
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 8 19.750000 1430.5700 72.4339
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 165 662.750000 38571.4600 58.1991
-----------------------------------------------------------------------------------------------------------------------
Total 6869.000000 299132.9900 43.5483
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1860
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 5 5.000000 250.0000 250.0000
D 226 229.000000 12260.1800 0.0000
S 3 1.500000 93.6000 0.0000
H 8327 6594.750000 285074.9100 285065.6100
T 0 0.000000 0.0000 0.0000
11 7.750000 301.1000 0.0000
Other 67 31.000000 1153.2000 0.0000
---------------------------------------------------------
Total 8639 6869.000000 299132.9900 285315.6100