CMS/EIP Fiscal Report Center: 04
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 992 3954.250000 147098.1000 37.2000
Subtotal (Total Children Is Unduplicated) 992 3954.250000 147098.1000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 39.500000 2968.4800 75.1514
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 123 163.500000 12304.3600 75.2560
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 10.000000 750.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 69 89.000000 6673.3800 74.9818
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 34.500000 1914.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 166 223.000000 12354.1500 55.3998
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 36.000000 2700.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 105 158.500000 11950.2900 75.3962
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 321.8600 53.6433
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92521TL-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
Subtotal (Total Children Is Unduplicated) 285 802.000000 54478.0000 67.9277
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 867 8523.000000 426870.0000 50.0845
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 8 46.000000 2364.0000 51.3913
OCCT-97530-OT SESSION BY LICENSED OT 19 112.000000 8115.6800 72.4614
OCCT-97530HM-OT SESSION BY OT ASST 16 114.500000 6676.9000 58.3135
PHY-97110-PT SESSION BY LICENSED PT 11 41.500000 3103.3400 74.7793
PHY-97110HM-PT SESSION BY PT ASST 17 99.500000 5825.5000 58.5477
PHY-97110TL-PT SESSION BY LICENSED PT 1 14.000000 1091.6800 77.9771
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 6.500000 481.7800 74.1200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 889 8959.000000 454672.8000 50.7504
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Total 13715.250000 656248.9000 47.8481
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Number of Children (Unduplicated) With at Least One Service 1347
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Center 04
Flag Claims Units Chgs Paid
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R 1 3.000000 111.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 613 1005.000000 41294.3500 0.0000
P 1979 3327.000000 133313.9100 130151.6300
D 26 43.750000 2141.9700 0.0000
S 0 0.000000 0.0000 0.0000
H 8966 8907.000000 451221.6700 0.0000
T 1 1.500000 55.8000 0.0000
342 427.500000 28073.6200 0.0000
Other 1 0.500000 35.9800 0.0000
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Total 11929 13715.250000 656248.9000 130151.6300