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:Program Patients
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
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.000000 485.8800 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 2 4.000000 323.9200 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 5 7.500000 449.4000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 16.000000 958.7200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 85.500000 6923.7900 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 42 80.500000 6518.8900 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 51.000000 4129.9800 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 78 144.000000 11661.1200 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 38.500000 3117.7300 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 16 26.500000 2145.9700 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 81 145.500000 8802.6000 60.4990
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 130 237.500000 14303.0800 60.2235
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) 261 1073.000000 73410.1700 68.4158
-----------------------------------------------------------------------------------------------------------------------
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
-----------------------------------------------------------------------------------------------------------------------
Total 3251.250000 243862.2000 75.0057
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 524
-----------------------------------------------------------------------------------------------------------------------
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 1321 1357.000000 105362.0800 105362.0800
D 50 50.000000 1533.7300 81.3200
S 86 85.750000 6863.9100 0.0000
H 138 230.000000 15762.9900 15762.9900
T 758 776.500000 59527.5100 59527.5100
500 556.500000 40540.4600 1665.3500
Other 102 195.500000 14271.5200 0.0000
---------------------------------------------------------
Total 2955 3251.250000 243862.2000 182399.2500