CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 1 1.750000 65.1000 37.2000
Subtotal (Total Children Is Unduplicated) 1 1.750000 65.1000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 12.500000 911.5000 72.9200
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.500000 479.0700 63.8760
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 293.4500 53.3545
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.000000 290.7600 58.1520
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 101 182.500000 12474.8100 68.3551
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 4.6000 4.6000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 75 131.500000 9472.7200 72.0359
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 34.500000 2526.4200 73.2296
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 41.500000 2327.5600 56.0858
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 174.3300 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 45.4200 45.4200
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 341.9600 56.9933
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 184.1900 36.8380
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 167.6300 55.8767
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 17 19.000000 1008.7900 53.0942
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 8.000000 411.2800 51.4100
Subtotal (Total Children Is Unduplicated) 183 471.500000 31379.8700 66.5533
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 15.000000 810.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 12.000000 628.0000 52.3333
OCCT-97530-OT SESSION BY LICENSED OT 22 140.750000 9514.4000 67.5979
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 36 301.250000 20917.1000 69.4344
PHY-97110GT-PT SESSION BY LICENSED PT 2 4.500000 278.8200 61.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 71 730.000000 52039.4800 71.2870
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 225.2400 75.0800
Subtotal (Total Children Is Unduplicated) 127 1207.500000 84485.0000 69.9669
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Total 1680.750000 115929.9700 68.9751
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Number of Children (Unduplicated) With at Least One Service 265
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Center 03
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 1283 1451.500000 98672.5100 98672.5100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 23 24.000000 1800.4700 1800.4700
T 0 0.000000 0.0000 0.0000
196 205.250000 15456.9900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1502 1680.750000 115929.9700 100472.9800