CMS/EIP Fiscal Report Center: 55
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 296 1207.500000 44993.4000 37.2616
Subtotal (Total Children Is Unduplicated) 296 1207.500000 44993.4000 37.2616
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 40.000000 3239.2000 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 647.8400 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 6 11.000000 659.1200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 34.000000 2753.3200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 971.7600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 14.000000 838.8800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 406.7700 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 174.3300 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 62 150.000000 11151.0900 74.3406
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 108 709.750000 38326.5000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 12.750000 688.5000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 100.000000 8132.0000 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 39 267.250000 17403.3200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 20 109.750000 8924.8700 81.3200
PHY-97110HM-PT SESSION BY PT ASST 22 122.750000 7993.4800 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 46 200.500000 16304.6600 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 9 60.750000 4940.1900 81.3200
Subtotal (Total Children Is Unduplicated) 224 1583.500000 102713.5200 64.8649
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Total 2941.000000 158858.0100 54.0150
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Number of Children (Unduplicated) With at Least One Service 308
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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 1494 1440.250000 61482.6700 0.0000
P 0 0.000000 0.0000 0.0000
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
1510 1500.750000 97375.3400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3004 2941.000000 158858.0100 0.0000