CMS/EIP Fiscal Report Center: 03
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 1 1.750000 65.1000 37.2000
Subtotal (Total Children Is Unduplicated) 1 1.750000 65.1000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.500000 425.6200 65.4800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 317.1100 57.6564
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 250.0000 62.5000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 83 148.500000 9948.7000 66.9946
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 4.6000 4.6000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 64 113.000000 8036.2100 71.1169
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 33.000000 2390.0000 72.4242
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 40.500000 2247.7500 55.5000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 52.3300 26.1650
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 167.6300 55.8767
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 57.8200 28.9100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 427.6900 47.5211
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 8.000000 411.2800 51.4100
Subtotal (Total Children Is Unduplicated) 143 383.000000 25106.4200 65.5520
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 60.750000 3889.9800 64.0326
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 30 120.750000 7703.8900 63.8003
PHY-97110GT-PT SESSION BY LICENSED PT 2 4.500000 278.8200 61.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 237.000000 15274.7100 64.4503
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 92 429.000000 27513.2800 64.1335
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Total 813.750000 52684.8000 64.7432
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Number of Children (Unduplicated) With at Least One Service 214
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Center 03
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 641 792.000000 51040.4000 51040.4000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 81.3200 81.3200
T 0 0.000000 0.0000 0.0000
21 20.750000 1563.0800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 663 813.750000 52684.8000 51121.7200