CMS/EIP Fiscal Report Center: 55
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 703 2981.000000 110911.8000 37.2062
Subtotal (Total Children Is Unduplicated) 703 2981.000000 110911.8000 37.2062
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 32 64.000000 4800.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 20.000000 1500.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 14 28.000000 1554.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 159 322.000000 24150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 34.000000 2550.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 66.000000 4900.0000 74.2424
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 36 72.000000 5400.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 22.000000 1673.9200 76.0873
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 93 186.000000 10323.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 15 30.000000 1673.8400 55.7947
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 321.8600 53.6433
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 726.4400 51.8886
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 6 6.000000 308.4600 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 565.5100 51.4100
Subtotal (Total Children Is Unduplicated) 271 915.000000 62784.1900 68.6166
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 221 1653.750000 82771.5000 50.0508
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 21.000000 1054.0000 50.1905
OCCT-97530-OT SESSION BY LICENSED OT 40 211.500000 15207.3600 71.9024
OCCT-97530HM-OT SESSION BY OT ASST 57 490.500000 28279.1200 57.6537
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 30 191.000000 13744.3600 71.9600
PHY-97110HM-PT SESSION BY PT ASST 30 202.250000 11684.7100 57.7736
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 113 751.250000 54153.5500 72.0846
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 11 66.000000 4749.3600 71.9600
Subtotal (Total Children Is Unduplicated) 438 3588.250000 211701.5600 58.9986
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Total 7484.250000 385397.5500 51.4945
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Number of Children (Unduplicated) With at Least One Service 733
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Center 55
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 428 429.000000 20180.6000 18.6000
P 3312 3365.000000 142797.6400 142770.2000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3534 3690.250000 222419.3100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7274 7484.250000 385397.5500 142788.8000