CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2025 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 4 6.750000 251.1000 37.2000
Subtotal (Total Children Is Unduplicated) 4 6.750000 251.1000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 283.4300 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 2.500000 202.4500 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 59.9200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.000000 242.9400 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 4.500000 269.6400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
Subtotal (Total Children Is Unduplicated) 10 27.000000 1997.5300 73.9826
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 85.000000 4590.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 18.000000 972.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 13.250000 1077.4900 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 1 0.500000 40.6600 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 4 19.000000 1536.9800 80.8937
OCCT-97530HM-OT SESSION BY OT ASST 2 3.000000 195.3600 65.1200
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.500000 65.1200 43.4133
PHY-97110-PT SESSION BY LICENSED PT 7 75.000000 5120.6800 68.2757
PHY-97110HM-PT SESSION BY PT ASST 5 28.250000 1839.6400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 63.500000 5163.8200 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 26.500000 2154.9800 81.3200
Subtotal (Total Children Is Unduplicated) 37 333.500000 22756.7300 68.2361
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Total 367.250000 25005.3600 68.0881
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Number of Children (Unduplicated) With at Least One Service 47
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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 174 168.250000 11505.7000 11505.7000
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
210 199.000000 13499.6600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 384 367.250000 25005.3600 11505.7000