CMS/EIP Fiscal Report Center: 57
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 909 3480.250000 129465.3000 37.2000
Subtotal (Total Children Is Unduplicated) 909 3480.250000 129465.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 404.9000 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 17.500000 1417.1500 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 14 25.000000 1498.0000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 209.7200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 74 124.000000 10041.5200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.500000 364.4100 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 92 151.000000 12196.3900 80.7708
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 9.000000 728.8200 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 53 82.000000 6640.3600 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 364.4100 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 213 362.000000 21691.0400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 11 17.000000 1018.6400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 11.000000 890.7800 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 174.3300 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 232.4400 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 232.4400 58.1100
Subtotal (Total Children Is Unduplicated) 257 836.500000 58806.0500 70.3001
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 754 4604.000000 248616.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 23 51.000000 2754.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 93.000000 7562.7600 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 13 67.000000 4363.0400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 4 19.000000 1545.0800 81.3200
PHY-97110HM-PT SESSION BY PT ASST 11 63.500000 4135.1200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 95.250000 7745.7300 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 13 42.000000 2735.0400 65.1200
Subtotal (Total Children Is Unduplicated) 789 5034.750000 279456.7700 55.5056
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Total 9351.500000 467728.1200 50.0164
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Number of Children (Unduplicated) With at Least One Service 1099
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Center 57
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2621 4021.750000 175439.6800 175439.6800
T 0 0.000000 0.0000 0.0000
5261 5329.750000 292288.4400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7882 9351.500000 467728.1200 175439.6800