CMS/EIP Fiscal Report Center: 04
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 1148 6432.500000 239289.0000 37.2000
Subtotal (Total Children Is Unduplicated) 1148 6432.500000 239289.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 14.500000 1144.3100 78.9179
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 28 33.000000 2642.4400 80.0739
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.000000 242.9400 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 12 14.000000 1112.7900 79.4850
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 7 8.500000 502.6900 59.1400
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 33 39.500000 2327.0600 58.9129
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 4 4.500000 364.4100 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 41.000000 3128.8200 76.3127
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 85 112.500000 8530.1900 75.8239
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 57 73.500000 5608.1800 76.3018
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 33.000000 1873.4900 56.7724
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 121 163.000000 9174.6800 56.2864
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 26.500000 2026.3700 76.4668
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 99.000000 7478.8200 75.5436
OCTH-97165-OT EVAL LOW COMPLEXITY 18 23.000000 1316.4300 57.2361
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 2 2.000000 109.5200 54.7600
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 7 9.000000 522.9900 58.1100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 4 6.000000 341.9600 56.9933
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 109.5200 54.7600
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 10 12.000000 690.6200 57.5517
SPCH-92521TL-EVAL OF SPEECH FLUENCY 6 6.000000 321.8600 53.6433
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 278 746.000000 50883.8700 68.2089
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 897 24062.00000 1266344.0000 52.6284
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 13 153.000000 8126.0000 53.1111
OCCT-97530-OT SESSION BY LICENSED OT 26 380.500000 29954.7800 78.7248
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 19 249.000000 15435.5400 61.9901
PHY-97110-PT SESSION BY LICENSED PT 14 114.500000 9039.7000 78.9493
PHY-97110HM-PT SESSION BY PT ASST 20 337.500000 21312.9400 63.1495
PHY-97110TL-PT SESSION BY LICENSED PT 2 16.000000 1254.3200 78.3950
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 18.500000 1457.6200 78.7903
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 919 25334.00000 1353150.1400 53.4124
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Total 32512.500000 1643323.0100 50.5443
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Number of Children (Unduplicated) With at Least One Service 1247
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Center 04
Flag Claims Units Chgs Paid
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R 77 103.500000 3850.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 1199 1890.250000 76281.0000 0.0000
P 3023 4837.000000 190288.0000 183318.5400
D 54 78.500000 3468.1200 0.0000
S 2 5.500000 204.6000 0.0000
H 25445 25255.000000 1347341.8000 216.0000
T 0 0.000000 0.0000 0.0000
283 338.250000 21682.4500 0.0000
Other 4 4.500000 206.8400 0.0000
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Total 30087 32512.500000 1643323.0100 183534.5400