CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2024 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 983 6708.000000 249546.9000 37.2014
Subtotal (Total Children Is Unduplicated) 983 6708.000000 249546.9000 37.2014
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.9200 7.9200
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 7.500000 601.3700 80.1827
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 8.500000 670.3900 78.8694
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 5.500000 436.4200 79.3491
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 4.500000 364.4100 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.000000 389.9500 77.9900
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 6 7.000000 419.4400 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 6.500000 376.2200 57.8800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 53 83.500000 6325.2900 75.7520
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 56 91.500000 7000.0400 76.5032
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 78.500000 5968.8800 76.0367
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 48 80.000000 6104.6500 76.3081
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 34.000000 2588.8700 76.1432
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 32 55.000000 4190.7800 76.1960
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 72.000000 4076.0800 56.6122
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 62 105.500000 5937.0200 56.2751
Subtotal (Total Children Is Unduplicated) 205 647.500000 45619.6900 70.4551
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EI Services,Class #03
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 1.000000 69.3500 69.3500
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 618 11273.00000 597005.6000 52.9589
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 172 1895.250000 99788.5000 52.6519
OCCT-97530-OT SESSION BY LICENSED OT 4 33.000000 2618.0400 79.3345
OCCT-97530GO-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 2 3.000000 234.6000 78.2000
OCCT-97530GT-OT SESSION BY LICENSED OT 2 6.000000 450.4800 75.0800
OCCT-97530HMGT-OT SESSION BY OT ASST 1 6.500000 413.2400 63.5754
PHY-97110-PT SESSION BY LICENSED PT 10 197.250000 15247.8300 77.3021
PHY-97110GT-PT SESSION BY LICENSED PT 2 9.250000 752.2100 81.3200
PHY-97110HM-PT SESSION BY PT ASST 9 141.750000 8859.1600 62.4985
PHY-97110HMGT-PT SESSION BY PT ASST 4 71.000000 4369.4000 61.5408
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 76.000000 5819.6800 76.5747
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 47.500000 3631.0400 76.4429
Subtotal (Total Children Is Unduplicated) 708 13762.50000 739421.7700 53.7273
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Total 21118.000000 1034588.3600 48.9908
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Number of Children (Unduplicated) With at Least One Service 1012
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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
24196 21118.000000 1034588.3600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 24196 21118.000000 1034588.3600 0.0000