CMS/EIP Fiscal Report Center: 05
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.000000 580.5000 72.5625
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 22.500000 1687.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 18.500000 1026.7500 55.5000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 3.000000 154.2300 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 173.7100 43.4275
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 338.2100 42.2763
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 4 15.000000 574.4300 38.2953
Subtotal (Total Children Is Unduplicated) 45 87.500000 5102.0600 58.3093
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 24 143.000000 7150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 0.500000 25.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 92.500000 6349.9000 68.6476
PHY-97110-PT SESSION BY LICENSED PT 39 159.000000 8374.1400 52.6675
PHY-97110GT-PT SESSION BY LICENSED PT 1 3.000000 215.8800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 172.250000 10220.6600 59.3362
Subtotal (Total Children Is Unduplicated) 94 570.250000 32335.5800 56.7042
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Total 657.750000 37437.6400 56.9177
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Number of Children (Unduplicated) With at Least One Service 121
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Center 05
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 712 657.750000 37437.6400 37437.6400
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 712 657.750000 37437.6400 37437.6400