CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 1938 10458.75000 388963.2000 37.1902
Subtotal (Total Children Is Unduplicated) 1938 10458.75000 388963.2000 37.1902
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 25.000000 2053.0300 82.1212
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 283.4300 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 236.9600 78.9867
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 3 6.000000 485.8800 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 33 53.500000 3135.0000 58.5981
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.000000 299.6000 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 13 23.500000 1903.0300 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 2 3.500000 283.4300 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 75.500000 5835.9200 77.2970
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 22 36.500000 2830.1900 77.5395
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 23.000000 1772.8400 77.0800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 28.500000 2167.4000 76.0491
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 29.000000 2255.7300 77.7838
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 18 30.500000 2386.1700 78.2351
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 140 227.500000 13048.3600 57.3554
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 43 71.500000 4027.9200 56.3345
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 150 253.000000 19540.1100 77.2336
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 105 195.000000 14992.7700 76.8860
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 5 24.000000 1394.6400 58.1100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 7 45.000000 2561.3500 56.9189
Subtotal (Total Children Is Unduplicated) 513 1169.500000 82009.6300 70.1237
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 164 1004.500000 52860.0000 52.6232
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 36 64.500000 3363.0000 52.1395
OCCT-97530-OT SESSION BY LICENSED OT 16 101.000000 8063.5600 79.8372
OCCT-97530GT-OT SESSION BY LICENSED OT 6 31.000000 2520.9200 81.3200
OCCT-97530TL-OT SESSION BY LICENSED OT 13 91.000000 7035.0800 77.3086
OCCT-97530TLGT-OT SESSION BY LICENSED OT 7 24.000000 1876.8000 78.2000
PHY-97110-PT SESSION BY LICENSED PT 12 77.750000 6303.9100 81.0792
PHY-97110GT-PT SESSION BY LICENSED PT 5 25.750000 2093.9900 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 14 120.500000 9572.0800 79.4363
PHY-97110TLGT-PT SESSION BY LICENSED PT 6 14.000000 1072.9600 76.6400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 83.250000 6472.7100 77.7503
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 162.6400 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 10 43.750000 3382.2500 77.3086
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 248 1684.000000 104851.8600 62.2636
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Total 13312.250000 575824.6900 43.2552
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Number of Children (Unduplicated) With at Least One Service 1960
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Center 01
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 2 0.750000 27.9000 0.0000
P 6 6.000000 304.0000 304.0000
D 454 458.250000 25388.1600 0.0000
S 885 770.000000 40718.0900 0.0000
H 15915 11979.000000 505643.4000 505634.1000
T 2 2.000000 162.6400 162.6400
45 32.750000 1218.3000 0.0000
Other 139 63.500000 2362.2000 0.0000
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Total 17448 13312.250000 575824.6900 506100.7400