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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1055 7610.250000 283101.3000 37.2000
Subtotal (Total Children Is Unduplicated) 1055 7610.250000 283101.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 20.000000 1598.6700 79.9335
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 28 46.500000 3726.7000 80.1441
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 47 82.000000 4878.2100 59.4904
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 56 90.000000 6827.7400 75.8638
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 65 103.500000 7909.0100 76.4156
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 15.500000 1180.4400 76.1574
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 48.000000 3725.5800 77.6163
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 13.000000 995.9300 76.6100
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 141 225.500000 12767.1900 56.6173
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 20 30.500000 1708.2200 56.0072
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 16.500000 1246.4700 75.5436
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 242.9400 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) 274 828.000000 54782.8000 66.1628
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 893 23620.50000 1243741.0000 52.6552
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) 945 26000.50000 1402901.9100 53.9567
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Total 34438.750000 1740786.0100 50.5473
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Number of Children (Unduplicated) With at Least One Service 1093
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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 6081 8263.750000 329260.1200 328079.0200
T 0 0.000000 0.0000 0.0000
26361 26173.000000 1411421.8900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 32444 34438.750000 1740786.0100 328079.0200