CMS/EIP Fiscal Report Center: 52
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 423 1097.000000 40566.6000 36.9796
Subtotal (Total Children Is Unduplicated) 423 1097.000000 40566.6000 36.9796
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 49 96.000000 7200.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 52.500000 3937.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 22.000000 1650.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 73 145.500000 8075.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 24.000000 1780.5000 74.1875
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
SCREEN-T1023-SCREENING 12 13.000000 650.0000 50.0000
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 5 22.000000 1151.5700 52.3441
Subtotal (Total Children Is Unduplicated) 133 428.000000 27887.3300 65.1573
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 297 1435.250000 71778.5000 50.0111
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 22 116.000000 5800.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 44.000000 3166.2400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 14 59.000000 4245.6400 71.9600
OCCT-97530TLGO-OT SESSION BY LICENSED OT 7 26.500000 1906.9400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 2 3.000000 215.8800 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 34 138.000000 9930.4800 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 9 44.000000 2532.6400 57.5600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 40 223.000000 16046.3400 71.9567
Subtotal (Total Children Is Unduplicated) 384 2089.750000 115694.6200 55.3629
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Total 3614.750000 184148.5500 50.9436
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Number of Children (Unduplicated) With at Least One Service 544
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Center 52
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 66 72.500000 3336.4000 0.0000
P 2555 2524.500000 121279.3500 120814.5100
D 0 0.000000 0.0000 0.0000
S 29 36.750000 1569.8600 110.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 150.0000 146.9600
895 925.250000 54767.5900 0.0000
Other 45 53.750000 3045.3500 2830.2500
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Total 3591 3614.750000 184148.5500 123901.7200