CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2025 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 309 1012.750000 37674.3000 37.2000
Subtotal (Total Children Is Unduplicated) 309 1012.750000 37674.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 89.8800 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 8.000000 479.3600 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.500000 526.3700 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 16.000000 1295.6800 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 283.4300 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 12 22.500000 1822.0500 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 5.500000 445.3900 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 10.000000 599.2000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 16 29.000000 1737.6800 59.9200
SPCH-92522TLGT-EVAL OF SPCH SOUND PROD 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 4.000000 232.4400 58.1100
Subtotal (Total Children Is Unduplicated) 33 115.000000 8176.9400 71.1038
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 321 2309.000000 124686.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 10.000000 540.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 20 113.250000 9209.4900 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 8 56.000000 3646.7200 65.1200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
PHY-97110-PT SESSION BY LICENSED PT 18 126.000000 10246.3200 81.3200
PHY-97110HM-PT SESSION BY PT ASST 2 12.000000 781.4400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 47 412.000000 33503.8400 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 7.000000 569.2400 81.3200
Subtotal (Total Children Is Unduplicated) 350 3048.250000 183427.0100 60.1745
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Total 4176.000000 229278.2500 54.9038
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Number of Children (Unduplicated) With at Least One Service 416
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Center 09
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 24 24.000000 1514.5600 0.0000
S 13 14.000000 809.9600 0.0000
H 769 853.250000 34331.9700 34202.8300
T 0 0.000000 0.0000 0.0000
3208 3250.250000 190291.2700 0.0000
Other 20 34.500000 2330.4900 0.0000
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Total 4034 4176.000000 229278.2500 34202.8300