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:TPIN
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 2 1.750000 65.1000 37.2000
Subtotal (Total Children Is Unduplicated) 2 1.750000 65.1000 37.2000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EXIT-EXIT-COS Exit 10 8.500000 425.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 6 9.000000 499.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 41.500000 3133.4300 75.5043
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 20 33.000000 2374.7600 71.9624
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 11.500000 871.4700 75.7800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 18.000000 1403.8200 77.9900
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 26.000000 1988.8700 76.4950
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 17.000000 1298.9200 76.4071
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 122 217.500000 12230.3700 56.2316
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 55 93.000000 5125.2200 55.1099
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 80 145.500000 11139.6100 76.5609
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 58 107.000000 8240.2800 77.0120
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 219.0400 54.7600
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 8 48.000000 2514.5800 52.3871
Subtotal (Total Children Is Unduplicated) 270 801.000000 52854.9200 65.9862
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EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 507 3232.750000 161819.5000 50.0563
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 89 336.500000 16829.0000 50.0119
INTR-T1013-INTERPRETER 1 1.500000 75.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 157.000000 11559.8000 73.6293
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 6 20.000000 1439.2000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 65 410.500000 29566.5800 72.0258
PHY-97110GT-PT SESSION BY LICENSED PT 7 19.750000 1486.7300 75.2775
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 97 641.500000 46564.8200 72.5874
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 54.500000 3949.9000 72.4752
SPL-92508HA-GROUP SPL SESSION PER CHILD 2 4.000000 55.8400 13.9600
Subtotal (Total Children Is Unduplicated) 628 4886.000000 273704.3300 56.0181
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Total 5688.750000 326624.3500 57.4158
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Number of Children (Unduplicated) With at Least One Service 776
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Center 01
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 0 0.000000 0.0000 0.0000
P 4681 4770.000000 265820.6300 265760.6300
D 43 44.000000 2589.8300 0.0000
S 1 1.000000 50.0000 0.0000
H 527 700.000000 46455.5300 0.0000
T 1 1.000000 71.9600 71.9600
149 172.750000 11636.4000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5402 5688.750000 326624.3500 265832.5900