CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.500000 18.6000 37.2000
Subtotal (Total Children Is Unduplicated) 1 0.500000 18.6000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.500000 364.4100 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 485.8800 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.000000 359.5200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 12.000000 719.0400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 40 71.000000 5749.5800 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 28 54.500000 4413.4100 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 37.000000 2996.2600 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 43 82.000000 6640.3600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 21.000000 1700.5800 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 13.500000 1093.2300 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 101.500000 6124.0000 60.3350
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 75 141.500000 8478.6800 59.9200
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 232.4400 58.1100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 116.2200 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 313.7600 62.7520
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 20 206.000000 11970.6600 58.1100
Subtotal (Total Children Is Unduplicated) 176 777.000000 52390.1200 67.4262
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 1 0.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 108.000000 5832.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 108.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 67 310.500000 25249.8600 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 3 4.000000 325.2800 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 9 54.000000 3465.1500 64.1694
PHY-97110-PT SESSION BY LICENSED PT 130 748.250000 60115.8100 80.3419
PHY-97110HM-PT SESSION BY PT ASST 2 6.000000 390.7200 65.1200
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 459.2200 229.6100
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 170 931.500000 74204.5000 79.6613
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 243.9600 81.3200
TRAV-TRAVS-Travel by mile 1 6.000000 2.6700 0.4450
Subtotal (Total Children Is Unduplicated) 302 2177.750000 170433.4300 78.2612
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Total 2955.250000 222842.1500 75.4055
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Number of Children (Unduplicated) With at Least One Service 439
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Center 09
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 1283 1289.000000 100171.3400 100171.3400
D 50 50.000000 1533.7300 81.3200
S 86 85.750000 6863.9100 0.0000
H 96 162.500000 11255.0700 11255.0700
T 730 725.500000 55997.7400 55997.7400
473 511.500000 37433.3900 1665.3500
Other 67 131.000000 9586.9700 0.0000
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Total 2785 2955.250000 222842.1500 169170.8200