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:TPIN
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 13 26.000000 967.2000 37.2000
Subtotal (Total Children Is Unduplicated) 13 26.000000 967.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 48.000000 3290.6800 68.5558
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 24.000000 1403.7200 58.4883
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 8.000000 623.9200 77.9900
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 10 22.000000 1300.5600 59.1164
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 56 119.500000 8297.3300 69.4337
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 30 62.000000 4508.7200 72.7213
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 34.000000 2172.4600 63.8959
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 311.9600 77.9900
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 54 106.500000 5954.9500 55.9150
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 8 9.000000 458.1800 50.9089
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 174.3300 58.1100
SCREEN-T1023-SCREENING 18 18.000000 947.7600 52.6533
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 24 32.000000 1501.8800 46.9338
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 116.2200 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 20 186.000000 9132.8600 49.1014
Subtotal (Total Children Is Unduplicated) 149 692.000000 41177.9700 59.5057
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 0.500000 25.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 223 2912.500000 153425.5400 52.6783
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 8 73.000000 3798.0000 52.0274
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 12.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 37 269.500000 19040.7200 70.6520
OCCT-97530GO-OT SESSION BY LICENSED OT 17 138.000000 8350.2600 60.5091
OCCT-97530HM-OT SESSION BY OT ASST 1 6.000000 390.7200 65.1200
OCCT-97530TL-OT SESSION BY LICENSED OT 1 5.000000 387.8800 77.5760
OCCT-97530TLGO-OT SESSION BY LICENSED OT 1 8.000000 631.8400 78.9800
PHY-97110-PT SESSION BY LICENSED PT 49 488.250000 34758.1400 71.1892
PHY-97110HM-PT SESSION BY PT ASST 10 121.000000 7442.1200 61.5051
PHY-97110TL-PT SESSION BY LICENSED PT 1 2.000000 60.0000 30.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 97 1111.500000 74057.0900 66.6281
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 1.500000 112.6200 75.0800
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 397.2400 79.4480
Subtotal (Total Children Is Unduplicated) 350 5143.750000 302939.1700 58.8946
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Total 5861.750000 345084.3400 58.8705
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Number of Children (Unduplicated) With at Least One Service 399
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Center 52
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 374 394.750000 25596.6900 21232.2700
D 214 226.000000 16553.7200 15.0000
S 0 0.000000 0.0000 0.0000
H 107 114.000000 8953.3100 0.0000
T 4076 4149.250000 236268.7400 207653.3400
932 975.750000 57671.8800 0.0000
Other 2 2.000000 40.0000 40.0000
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Total 5705 5861.750000 345084.3400 228940.6100