CMS/EIP Fiscal Report Center: 57
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 353 1171.250000 43570.5000 37.2000
Subtotal (Total Children Is Unduplicated) 353 1171.250000 43570.5000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 404.9000 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 10.500000 850.2900 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 283.4300 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.000000 323.9200 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 13 23.000000 1378.1600 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 329.5600 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 10.000000 809.8000 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.000000 890.7800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 21.000000 1258.3200 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
PSTF-97164-PT RE-EVAL EST PLAN CARE 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) 31 101.500000 7108.3900 70.0334
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 369 3683.000000 198882.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 13 34.000000 1836.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 21.500000 1748.3800 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 65.1200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 1 0.500000 40.6600 81.3200
PHY-97110HM-PT SESSION BY PT ASST 7 27.500000 1790.8000 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 6.750000 548.9100 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 25.500000 1660.5600 65.1200
Subtotal (Total Children Is Unduplicated) 386 3799.750000 206572.4300 54.3647
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Total 5072.500000 257251.3200 50.7149
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Number of Children (Unduplicated) With at Least One Service 463
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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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 823 1212.750000 48227.6100 48227.6100
T 0 0.000000 0.0000 0.0000
3846 3859.750000 209023.7100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4669 5072.500000 257251.3200 48227.6100