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: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 6 8.500000 316.2000 37.2000
Subtotal (Total Children Is Unduplicated) 6 8.500000 316.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 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 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 60 128.500000 8734.1000 67.9696
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 15.500000 1162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 71.000000 5175.0000 72.8873
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 41.000000 2850.3000 69.5195
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 6.000000 285.2000 47.5333
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 69 135.000000 7492.5000 55.5000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 6 6.000000 300.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 10.000000 462.6900 46.2690
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 7 35.000000 1542.3000 44.0657
Subtotal (Total Children Is Unduplicated) 121 479.000000 30267.0000 63.1879
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EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 188 935.750000 46800.0000 50.0134
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 36.000000 1800.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 175.000000 11594.9200 66.2567
OCCT-97530GO-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530TLGO-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 43 205.250000 13488.8800 65.7193
PHY-97110HM-PT SESSION BY PT ASST 11 62.000000 3568.7200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 74 372.500000 23639.7700 63.4625
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 304 1794.500000 101446.0100 56.5316
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Total 2282.000000 132029.2100 57.8568
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Number of Children (Unduplicated) With at Least One Service 378
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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 0 0.000000 0.0000 0.0000
P 152 178.750000 11603.7000 12694.4400
D 132 149.750000 10282.1400 15.0000
S 0 0.000000 0.0000 0.0000
H 10 15.000000 1109.8000 0.0000
T 1375 1474.500000 82073.5500 73630.8200
420 464.000000 26960.0200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2089 2282.000000 132029.2100 86340.2600