CMS/EIP Fiscal Report Center: 57
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 965 4289.750000 159578.7000 37.2000
Subtotal (Total Children Is Unduplicated) 965 4289.750000 159578.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 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 3 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 10 17.500000 971.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 95 156.000000 11700.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 12 19.000000 1425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 93 148.000000 11100.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 23.500000 1762.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 47 73.000000 5475.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 17.000000 1277.9900 75.1759
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 210 344.000000 19131.0000 55.6134
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 38 59.500000 3302.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 40.000000 3000.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 15 15.000000 777.8500 51.8567
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 616.9200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 7.000000 359.8700 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 25 25.000000 1285.2500 51.4100
Subtotal (Total Children Is Unduplicated) 325 990.500000 64454.3200 65.0725
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 886 8416.750000 421818.5000 50.1166
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 30 122.000000 6308.0000 51.7049
OCCT-97530-OT SESSION BY LICENSED OT 48 409.000000 29431.6400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 33 145.000000 8352.0000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 4 7.500000 539.7000 71.9600
OCCT-97530TLHM-OT SESSION BY OT ASST 1 3.000000 172.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 11 129.000000 9275.6400 71.9042
PHY-97110HM-PT SESSION BY PT ASST 29 287.250000 16664.2700 58.0131
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 51 305.500000 22057.2000 72.2003
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 162.6400 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 40 193.000000 11137.7400 57.7085
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 3.500000 251.8600 71.9600
Subtotal (Total Children Is Unduplicated) 944 10023.50000 526171.9900 52.4938
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Total 15303.750000 750205.0100 49.0210
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Number of Children (Unduplicated) With at Least One Service 1168
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Center 57
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 1 1.000000 50.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3476 5177.500000 218624.6900 217462.1900
T 0 0.000000 0.0000 0.0000
10273 10125.250000 531530.3200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 13750 15303.750000 750205.0100 217462.1900