CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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 1051 3558.750000 132422.7000 37.2105
Subtotal (Total Children Is Unduplicated) 1051 3558.750000 132422.7000 37.2105
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 67 108.000000 7950.0000 73.6111
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 66 115.000000 8625.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 60 102.000000 7545.7500 73.9779
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 55 94.500000 7087.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 35.500000 2662.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 30 56.500000 4237.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 54 89.000000 4913.2500 55.2051
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 68 123.500000 6854.2500 55.5000
Subtotal (Total Children Is Unduplicated) 215 735.000000 50642.2500 68.9010
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 537 4070.250000 203980.1000 50.1149
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 131 620.000000 30995.5000 49.9927
OCCT-97530-OT SESSION BY LICENSED OT 2 7.000000 503.7200 71.9600
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
OCCT-97530HMGT-OT SESSION BY OT ASST 1 3.500000 201.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 6 65.000000 4545.6400 69.9329
PHY-97110HM-PT SESSION BY PT ASST 8 48.250000 2770.4400 57.4184
PHY-97110HMGT-PT SESSION BY PT ASST 4 25.000000 1439.0000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 28.000000 1970.9600 70.3914
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 24.750000 1781.0100 71.9600
Subtotal (Total Children Is Unduplicated) 633 4896.750000 248547.7700 50.7577
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Total 9190.500000 431612.7200 46.9629
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Number of Children (Unduplicated) With at Least One Service 1118
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Center 06
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
10119 9190.500000 431612.7200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10119 9190.500000 431612.7200 0.0000