CMS/EIP Fiscal Report Center: 52
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 2 2.000000 74.4000 37.2000
Subtotal (Total Children Is Unduplicated) 2 2.000000 74.4000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 4.000000 146.9600 36.7400
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 239.6800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 6.000000 283.7600 47.2933
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 6 27.000000 1615.3900 59.8293
Subtotal (Total Children Is Unduplicated) 21 59.000000 3567.7100 60.4697
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 93 521.750000 28147.5000 53.9483
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 10.000000 540.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 23.000000 1870.3600 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 12 59.000000 3722.8400 63.0990
OCCT-97530HM-OT SESSION BY OT ASST 1 6.000000 390.7200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 15 49.000000 3650.7200 74.5045
PHY-97110HM-PT SESSION BY PT ASST 3 9.000000 586.0800 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 39 189.500000 14231.9900 75.1028
Subtotal (Total Children Is Unduplicated) 140 867.250000 53140.2100 61.2744
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Total 928.250000 56782.3200 61.1714
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Number of Children (Unduplicated) With at Least One Service 149
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Center 52
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 42 43.000000 2834.9300 1682.5100
D 8 8.000000 650.5600 0.0000
S 0 0.000000 0.0000 0.0000
H 49 47.000000 3781.9500 0.0000
T 683 679.250000 39292.5700 33102.4900
151 151.000000 10222.3100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 933 928.250000 56782.3200 34785.0000