CMS/EIP Fiscal Report Center: 57
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1013 7294.000000 271336.8000 37.2000
Subtotal (Total Children Is Unduplicated) 1013 7294.000000 271336.8000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 18.500000 1477.2000 79.8486
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 7.000000 545.9300 77.9900
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 25 41.500000 3339.7400 80.4757
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.000000 554.9000 79.2714
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 13.000000 1022.8400 78.6800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 43 75.500000 4501.9900 59.6290
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 12.500000 733.5300 58.6824
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 47 76.500000 5806.2700 75.8990
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 54 88.000000 6716.6100 76.3251
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 14.000000 1067.9400 76.2814
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 34.000000 2639.7000 77.6382
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 111 183.000000 10350.9800 56.5627
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 25.500000 1421.8800 55.7600
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.500000 1171.4700 75.5787
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
OCTF-97168-OT RE-EVAL EST PLAN CARE 19 19.000000 1010.2900 53.1732
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 616.9200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 11 14.000000 766.6400 54.7600
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 8.000000 431.3800 53.9225
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 29 32.000000 1692.0200 52.8756
Subtotal (Total Children Is Unduplicated) 235 715.500000 47190.9500 65.9552
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 892 23615.50000 1243491.0000 52.6557
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 41 242.000000 12796.0000 52.8760
OCCT-97530-OT SESSION BY LICENSED OT 52 611.000000 45797.4400 74.9549
OCCT-97530HM-OT SESSION BY OT ASST 35 205.000000 12304.3200 60.0211
OCCT-97530TL-OT SESSION BY LICENSED OT 4 7.500000 539.7000 71.9600
OCCT-97530TLHM-OT SESSION BY OT ASST 1 7.000000 433.2800 61.8971
PHY-97110-PT SESSION BY LICENSED PT 14 155.000000 11408.6800 73.6044
PHY-97110HM-PT SESSION BY PT ASST 34 430.000000 25975.1900 60.4074
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 59 432.500000 32388.0600 74.8857
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 162.6400 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 43 284.500000 17103.7400 60.1186
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 3.500000 251.8600 71.9600
Subtotal (Total Children Is Unduplicated) 944 25995.50000 1402651.9100 53.9575
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Total 34005.000000 1721179.6600 50.6155
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Number of Children (Unduplicated) With at Least One Service 1050
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Center 57
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 0 0.000000 0.0000 0.0000
D 2 2.000000 104.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5853 7838.000000 310076.9000 308895.8000
T 0 0.000000 0.0000 0.0000
26354 26165.000000 1410998.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 32209 34005.000000 1721179.6600 308895.8000