CMS/EIP Fiscal Report Center: 52
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 408 1256.250000 46314.0000 36.8669
Subtotal (Total Children Is Unduplicated) 408 1256.250000 46314.0000 36.8669
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 12.000000 971.7600 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 9 18.000000 1078.5600 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 55.000000 4453.9000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 647.8400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 28.000000 2267.4400 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 41.000000 3320.1800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 65 129.000000 7729.6800 59.9200
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SCREEN-T1023-SCREENING 4 4.000000 215.9200 53.9800
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 5.000000 290.5500 58.1100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 106 316.000000 22088.5500 69.9005
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 250 1053.000000 56862.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 16 67.000000 3618.0000 54.0000
OCCT-97530GO-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 23 90.500000 7359.4600 81.3200
OCCT-97530TLHM-OT SESSION BY OT ASST 3 5.000000 325.6000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 21.3200 21.3200
PHY-97110TL-PT SESSION BY LICENSED PT 28 79.750000 6485.2700 81.3200
PHY-97110TLHM-PT SESSION BY PT ASST 7 36.000000 2344.3200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 1.500000 121.9800 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 34 130.000000 10612.2600 81.6328
Subtotal (Total Children Is Unduplicated) 323 1465.750000 87912.8500 59.9781
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Total 3038.000000 156315.4000 51.4534
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Number of Children (Unduplicated) With at Least One Service 512
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Center 52
Flag Claims Units Chgs Paid
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R 55 59.000000 3869.5500 0.0000
U 0 0.000000 0.0000 0.0000
B 575 624.500000 26538.6400 0.0000
P 1425 1521.000000 78385.7000 78296.9500
D 1 1.000000 81.3200 0.0000
S 34 40.000000 1592.3600 32.3900
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
754 785.250000 45578.1300 0.0000
Other 6 7.250000 269.7000 241.8000
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Total 2850 3038.000000 156315.4000 78571.1400