CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2025 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 299 981.500000 36511.8000 37.2000
Subtotal (Total Children Is Unduplicated) 299 981.500000 36511.8000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 7.000000 566.8600 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.000000 323.9200 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 149.8000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 13.000000 778.9600 59.9200
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 3 3.000000 242.9400 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 242.9400 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 9.000000 728.8200 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 364.4100 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.000000 119.8400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 10.000000 599.2000 59.9200
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 232.4400 58.1100
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 174.3300 58.1100
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 34 74.500000 5179.4200 69.5224
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 360 3746.000000 202284.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 25.000000 1350.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 55.000000 4472.6000 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 5 44.000000 2865.2800 65.1200
PHY-97110-PT SESSION BY LICENSED PT 4 17.500000 1423.1000 81.3200
PHY-97110HM-PT SESSION BY PT ASST 6 55.000000 3570.4800 64.9178
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.500000 284.6200 81.3200
Subtotal (Total Children Is Unduplicated) 373 3946.000000 216250.0800 54.8024
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Total 5002.000000 257941.3000 51.5676
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Number of Children (Unduplicated) With at Least One Service 465
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Center 04
Flag Claims Units Chgs Paid
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R 37 52.500000 1953.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 454 728.250000 27353.5800 0.0000
P 103 178.500000 6880.7500 6880.7500
D 3 3.500000 130.2000 0.0000
S 0 0.000000 0.0000 0.0000
H 3983 3950.000000 216503.0700 0.0000
T 0 0.000000 0.0000 0.0000
66 88.250000 5083.5000 0.0000
Other 1 1.000000 37.2000 0.0000
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Total 4647 5002.000000 257941.3000 6880.7500