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:TPIN
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 8 18.250000 678.9000 37.2000
Subtotal (Total Children Is Unduplicated) 8 18.250000 678.9000 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 24.2800 24.2800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 80.9800 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.000000 80.9800 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 80.9800 80.9800
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 59.9200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 40.000000 3239.2000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 54 66.500000 5385.1700 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 40 45.000000 3644.1000 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 51 68.000000 5506.6400 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 23.000000 1862.5400 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 21 25.000000 2024.5000 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 54.500000 3307.7600 60.6928
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 52 71.000000 4254.3200 59.9200
Subtotal (Total Children Is Unduplicated) 167 398.000000 29551.3700 74.2497
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EI Services,Class #03
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 87.250000 4711.5000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 5.000000 270.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 16.000000 1301.1200 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 5 22.500000 1776.7600 78.9671
OCCT-97530HM-OT SESSION BY OT ASST 2 6.500000 423.2800 65.1200
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.500000 97.6800 65.1200
PHY-97110-PT SESSION BY LICENSED PT 12 77.750000 6282.6300 80.8055
PHY-97110GT-PT SESSION BY LICENSED PT 4 10.500000 848.0800 80.7695
PHY-97110HM-PT SESSION BY PT ASST 3 13.000000 681.4400 52.4185
PHY-97110HMGT-PT SESSION BY PT ASST 1 1.000000 65.1200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 91.250000 7420.4500 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 48.000000 3903.3600 81.3200
Subtotal (Total Children Is Unduplicated) 69 382.250000 27887.7400 72.9568
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Total 798.500000 58118.0100 72.7840
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Number of Children (Unduplicated) With at Least One Service 235
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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 83 80.250000 5714.6200 5714.6200
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
658 703.250000 51315.0500 0.0000
Other 10 15.000000 1088.3400 0.0000
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Total 751 798.500000 58118.0100 5714.6200