CMS/EIP Fiscal Report Center: 55
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 785 7064.250000 262799.4000 37.2013
Subtotal (Total Children Is Unduplicated) 785 7064.250000 262799.4000 37.2013
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 91 180.000000 14181.7200 78.7873
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 18 36.000000 2843.5200 78.9867
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 12.000000 911.9600 75.9967
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 311.9600 77.9900
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 20 40.000000 3119.6000 77.9900
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 311.9600 77.9900
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 48 91.500000 5358.9200 58.5674
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 24.000000 1420.4000 59.1833
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 160 324.000000 24874.0800 76.7719
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 22 46.000000 3581.5600 77.8600
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 58.000000 4421.7600 76.2372
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 635.8800 79.4850
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 64.000000 4907.6400 76.6819
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 18.000000 1397.8400 77.6578
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 105 210.000000 11946.7200 56.8891
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 16 32.000000 1837.8800 57.4338
OCTF-97168-OT RE-EVAL EST PLAN CARE 27 30.000000 1716.5000 57.2167
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 174.3300 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 160.9300 53.6433
OCTH-97167-OT EVAL HIGH COMPLEXITY 22 22.000000 1191.3200 54.1509
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 16 17.000000 967.7700 56.9276
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 8 8.000000 431.3800 53.9225
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 22 22.000000 1204.7200 54.7600
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 402 1265.500000 88479.0800 69.9163
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 265 4914.000000 258805.0000 52.6669
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 24 89.250000 4739.5000 53.1036
OCCT-97530-OT SESSION BY LICENSED OT 60 762.500000 59986.6000 78.6710
OCCT-97530HM-OT SESSION BY OT ASST 82 1602.500000 100722.6400 62.8534
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 1 2.000000 130.2400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 41 611.000000 47898.7600 78.3940
PHY-97110HM-PT SESSION BY PT ASST 42 618.250000 38822.3100 62.7939
PHY-97110HMGT-PT SESSION BY PT ASST 1 1.000000 65.1200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 137 1902.000000 147835.5000 77.7263
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 19 241.750000 19041.3500 78.7646
Subtotal (Total Children Is Unduplicated) 517 10745.25000 678104.6200 63.1074
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Total 19075.000000 1029383.1000 53.9650
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Number of Children (Unduplicated) With at Least One Service 796
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Center 55
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 4637 4338.750000 186783.3700 18.6000
P 4555 4307.750000 179593.0400 179138.1200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
10359 10428.500000 663006.6900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 19551 19075.000000 1029383.1000 179156.7200