CMS/EIP Fiscal Report Center: 09
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 968 3290.750000 122415.9000 37.2000
Subtotal (Total Children Is Unduplicated) 968 3290.750000 122415.9000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 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 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 10.000000 675.0000 67.5000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 411.0000 68.5000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 7 14.000000 777.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 89 168.000000 12600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 45 80.000000 6000.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 51 99.000000 7425.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 50 96.000000 7125.0000 74.2188
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 50.000000 3750.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 135 252.000000 14025.0000 55.6548
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 89 165.000000 9157.5000 55.5000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 18.000000 925.3800 51.4100
Subtotal (Total Children Is Unduplicated) 263 992.500000 65145.4300 65.6377
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 724 5541.500000 277959.9600 50.1597
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 34 64.500000 3187.0000 49.4109
OCCT-97530-OT SESSION BY LICENSED OT 28 168.000000 12017.4800 71.5326
OCCT-97530GOGT-OT SESSION BY LICENSED OT 4 5.000000 359.8000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 4 7.000000 503.7200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 5 42.000000 2419.2000 57.6000
OCCT-97530TLGO-OT SESSION BY LICENSED OT 1 3.000000 234.6000 78.2000
PHY-97110-PT SESSION BY LICENSED PT 26 194.000000 13960.2400 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 307.000000 22091.7200 71.9600
Subtotal (Total Children Is Unduplicated) 762 6333.000000 332805.6800 52.5510
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Total 10616.250000 520367.0100 49.0161
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Number of Children (Unduplicated) With at Least One Service 1149
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Center 09
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 0 0.000000 0.0000 0.0000
D 19 19.000000 967.4100 0.0000
S 0 0.000000 0.0000 0.0000
H 3689 3893.750000 159698.3900 159550.0700
T 0 0.000000 0.0000 0.0000
6446 6642.500000 355496.7100 355496.7100
Other 31 61.000000 4204.5000 0.0000
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Total 10185 10616.250000 520367.0100 515046.7800