CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2025 ending 03/31/2025 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 992 3175.250000 118128.6000 37.2029
Subtotal (Total Children Is Unduplicated) 992 3175.250000 118128.6000 37.2029
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 202.4500 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 2.500000 202.4500 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.500000 202.4500 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 3.000000 242.9400 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 202.4500 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.500000 209.7200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 5.500000 329.5600 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 71 86.000000 6943.2200 80.7351
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 55 67.500000 5466.1500 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 59.500000 4818.3100 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 47 62.000000 5020.7600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 27.500000 2226.9500 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 23 31.000000 2478.7900 79.9610
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 77 95.000000 5683.5000 59.8263
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 61 78.500000 4703.7200 59.9200
Subtotal (Total Children Is Unduplicated) 212 531.000000 39095.3800 73.6260
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 472 3003.750000 167116.5000 55.6360
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 102 525.250000 28269.0000 53.8201
OCCT-97530-OT SESSION BY LICENSED OT 2 8.000000 650.5600 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
PHY-97110-PT SESSION BY LICENSED PT 4 42.000000 3415.4400 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.500000 121.9800 81.3200
PHY-97110HM-PT SESSION BY PT ASST 4 28.000000 1823.3600 65.1200
PHY-97110HMGT-PT SESSION BY PT ASST 2 13.000000 781.4400 60.1108
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 24.500000 1992.3400 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 17.500000 1423.1000 81.3200
Subtotal (Total Children Is Unduplicated) 547 3664.500000 205675.0400 56.1264
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Total 7370.750000 362899.0200 49.2350
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Number of Children (Unduplicated) With at Least One Service 1048
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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
8724 7370.750000 362899.0200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8724 7370.750000 362899.0200 0.0000