CMS/EIP Fiscal Report Center: 52
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 501 2314.750000 85513.5000 36.9429
Subtotal (Total Children Is Unduplicated) 501 2314.750000 85513.5000 36.9429
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 32.000000 2567.4400 80.2325
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 18.000000 1409.8000 78.3222
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 10.000000 809.8000 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 19 38.000000 2250.4400 59.2221
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 52 103.000000 7964.2000 77.3223
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 274.4600 78.4171
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 57.000000 4382.6400 76.8884
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 28.000000 2219.6000 79.2714
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 74 147.500000 8433.7700 57.1781
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 590.3600 59.0360
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 16.000000 1200.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 3 3.000000 167.6300 55.8767
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 109.5200 54.7600
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 5 5.000000 277.1500 55.4300
SCREEN-T1023-SCREENING 34 36.000000 1891.5400 52.5428
SPCH-92521TL-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 547.6000 54.7600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 9.000000 522.9900 58.1100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 6 31.000000 1674.5600 54.0181
Subtotal (Total Children Is Unduplicated) 180 572.500000 38144.2100 66.6274
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 361 4289.000000 225893.0000 52.6680
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 29 395.000000 20866.0000 52.8253
OCCT-97530-OT SESSION BY LICENSED OT 15 45.000000 3175.9200 70.5760
OCCT-97530GO-OT SESSION BY LICENSED OT 3 7.000000 396.5200 56.6457
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 14 60.000000 4373.7600 72.8960
OCCT-97530TLGO-OT SESSION BY LICENSED OT 31 235.000000 18902.8200 80.4375
OCCT-97530TLHM-OT SESSION BY OT ASST 1 2.000000 130.2400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 5 7.000000 421.1600 60.1657
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 65.1200 65.1200
PHY-97110TL-PT SESSION BY LICENSED PT 39 393.500000 30801.3400 78.2753
PHY-97110TLHM-PT SESSION BY PT ASST 11 134.000000 8425.8400 62.8794
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 3.500000 284.6200 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 52 560.500000 43532.5000 77.6673
Subtotal (Total Children Is Unduplicated) 453 6133.500000 357340.8000 58.2605
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Total 9020.750000 480998.5100 53.3213
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Number of Children (Unduplicated) With at Least One Service 562
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Center 52
Flag Claims Units Chgs Paid
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R 170 157.750000 6045.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 693 666.750000 32009.6500 162.0000
P 5737 5492.500000 283866.9000 283086.5500
D 0 0.000000 0.0000 0.0000
S 58 69.750000 3393.8600 701.8800
H 4 4.250000 174.9000 0.0000
T 1 2.000000 150.0000 146.9600
2546 2583.250000 152956.3500 0.0000
Other 42 44.500000 2401.2500 2186.1500
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Total 9251 9020.750000 480998.5100 286283.5400