CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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 681 2713.250000 100867.8000 37.1760
Subtotal (Total Children Is Unduplicated) 681 2713.250000 100867.8000 37.1760
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 37.000000 2972.3400 80.3335
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 485.8800 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 10.000000 809.8000 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 13 24.500000 1468.0400 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 359.5200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 148 298.000000 23952.6400 80.3780
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 21 46.000000 3725.0800 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 34.000000 2753.3200 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 647.8400 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 46 92.000000 7450.1600 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 971.7600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 91 182.000000 10861.2400 59.6771
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 20.000000 1198.4000 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 12 12.000000 697.3200 58.1100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 348.6600 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 7.000000 406.7700 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 290.5500 58.1100
Subtotal (Total Children Is Unduplicated) 239 814.500000 59968.0500 73.6256
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 238 1699.250000 91759.5000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 17 48.000000 2592.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 43 224.500000 18256.3400 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 51 456.250000 29711.0000 65.1200
OCCT-97530TLHM-OT SESSION BY OT ASST 1 2.000000 130.2400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 27 155.500000 12645.2600 81.3200
PHY-97110HM-PT SESSION BY PT ASST 20 139.500000 9100.5200 65.2367
PHY-97110HMGT-PT SESSION BY PT ASST 1 1.000000 65.1200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 94 653.500000 53142.6200 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 8.000000 650.5600 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 16 72.000000 5855.0400 81.3200
Subtotal (Total Children Is Unduplicated) 439 3459.500000 223908.2000 64.7227
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Total 6987.250000 384744.0500 55.0637
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Number of Children (Unduplicated) With at Least One Service 716
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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 1502 1558.750000 72003.7400 0.0000
P 1919 1918.250000 81603.4600 81004.4000
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
3397 3510.250000 231136.8500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6818 6987.250000 384744.0500 81004.4000