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: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 700 1809.250000 67266.9000 37.1794
Subtotal (Total Children Is Unduplicated) 700 1809.250000 67266.9000 37.1794
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 283.4300 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 9.500000 769.3100 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 3 5.000000 299.6000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 9.500000 569.2400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 60.000000 4858.8000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 68 127.000000 10284.4600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 47.000000 3806.0600 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 80 154.000000 12470.9200 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 47.000000 3806.0600 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 24 48.500000 3927.5300 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 77 133.500000 7999.3200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 155 293.500000 17658.8000 60.1663
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 3 34.000000 1975.7400 58.1100
Subtotal (Total Children Is Unduplicated) 252 980.500000 69374.7300 70.7544
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 532 2841.000000 153414.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 22.000000 1188.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 20 119.000000 9677.0800 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 10 60.000000 3907.2000 65.1200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 4 15.000000 1219.8000 81.3200
PHY-97110-PT SESSION BY LICENSED PT 27 161.750000 13072.1900 80.8172
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
PHY-97110HM-PT SESSION BY PT ASST 2 7.000000 455.8400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 226.000000 18300.0000 80.9735
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 3 16.000000 1301.1200 81.3200
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 7.000000 569.2400 81.3200
Subtotal (Total Children Is Unduplicated) 577 3476.750000 203267.1100 58.4647
-----------------------------------------------------------------------------------------------------------------------
Total 6266.500000 339908.7400 54.2422
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1020
-----------------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 12 12.000000 648.0000 0.0000
S 125 126.000000 7459.6800 0.0000
H 1670 1937.250000 85988.3000 85476.8000
T 0 0.000000 0.0000 0.0000
3696 3851.750000 220573.4700 55312.1600
Other 178 339.500000 25239.2900 0.0000
---------------------------------------------------------
Total 5681 6266.500000 339908.7400 140788.9600