CMS/EIP Fiscal Report Center: 09
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 1089 7975.750000 296697.9000 37.2000
Subtotal (Total Children Is Unduplicated) 1089 7975.750000 296697.9000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 15.500000 1219.3100 78.6652
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 12.000000 959.8000 79.9833
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 611.9600 76.4950
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 14 27.000000 2051.6600 75.9874
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 11.500000 856.3900 74.4687
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 445.3900 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 17 31.000000 1795.6400 57.9239
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 20 38.500000 2262.7200 58.7719
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 91 168.000000 12728.5700 75.7653
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 56 100.500000 7848.4600 78.0941
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 79.500000 6010.3400 75.6018
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 67 128.500000 10006.8900 77.8746
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 49.000000 3722.8400 75.9763
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 23.000000 1829.6500 79.5500
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 135 245.500000 13807.9000 56.2440
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 114 213.000000 12283.5200 57.6691
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 167.6300 55.8767
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92522TLGT-EVAL OF SPCH SOUND PROD 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 5 108.000000 6155.2800 56.9933
Subtotal (Total Children Is Unduplicated) 320 1275.000000 85202.0300 66.8251
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 856 16074.50000 846767.9600 52.6777
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 54 151.500000 7889.0000 52.0726
OCCT-97530-OT SESSION BY LICENSED OT 47 570.750000 44781.3900 78.4606
OCCT-97530GOGT-OT SESSION BY LICENSED OT 4 5.000000 359.8000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 4 7.000000 503.7200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 14 249.000000 15899.0400 63.8516
OCCT-97530TLGO-OT SESSION BY LICENSED OT 4 49.000000 3975.3200 81.1290
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 2 2.000000 162.6400 81.3200
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
PHY-97110-PT SESSION BY LICENSED PT 37 712.000000 56002.6800 78.6554
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 153.2800 76.6400
PHY-97110HM-PT SESSION BY PT ASST 2 29.000000 1888.4800 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 83 1426.000000 113010.4800 79.2500
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 325.2800 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 4 20.000000 1626.4000 81.3200
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 7.000000 569.2400 81.3200
Subtotal (Total Children Is Unduplicated) 902 19309.75000 1093996.0300 56.6551
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Total 28560.500000 1475895.9600 51.6761
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Number of Children (Unduplicated) With at Least One Service 1223
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Center 09
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 15 15.000000 810.0000 810.0000
D 77 78.500000 4302.9700 0.0000
S 13 14.000000 809.9600 0.0000
H 8289 8638.000000 345571.8900 344959.6300
T 0 0.000000 0.0000 0.0000
19439 19674.000000 1114481.8600 679552.5700
Other 76 141.000000 9919.2800 0.0000
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Total 27909 28560.500000 1475895.9600 1025322.2000