CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2025 ending 03/31/2025 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 777 2853.250000 106140.9000 37.2000
Subtotal (Total Children Is Unduplicated) 777 2853.250000 106140.9000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 202.4500 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 6.000000 485.8800 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.500000 121.4700 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 4.500000 364.4100 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.500000 209.7200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 9.000000 539.2800 59.9200
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 41.500000 3360.6700 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 69 84.000000 6802.3200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 15.500000 1255.1900 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 46 54.000000 4372.9200 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 68.000000 4074.5600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 119 141.500000 8478.6800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 31.500000 2550.8700 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 46.000000 3725.0800 80.9800
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 232.4400 58.1100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 232.4400 58.1100
Subtotal (Total Children Is Unduplicated) 200 525.500000 37536.6200 71.4303
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 685 4259.000000 229986.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 40.000000 2160.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 52.000000 4228.6400 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 5 16.000000 1041.9200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 3 9.500000 772.5400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 11 62.000000 4037.4400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.500000 121.9800 81.3200
Subtotal (Total Children Is Unduplicated) 704 4440.000000 242348.5200 54.5830
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Total 7818.750000 386026.0400 49.3718
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Number of Children (Unduplicated) With at Least One Service 1177
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Center 04
Flag Claims Units Chgs Paid
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R 69 94.250000 3506.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 1202 1929.750000 76993.1000 0.0000
P 242 446.750000 16731.7400 16737.8000
D 18 32.250000 1199.7000 0.0000
S 4 10.250000 381.3000 0.0000
H 4461 4446.000000 242713.6200 0.0000
T 0 0.000000 0.0000 0.0000
589 859.500000 44500.4800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6585 7818.750000 386026.0400 16737.8000