CMS/EIP Fiscal Report Center: 55
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 6 12.000000 900.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 53 104.114267 7808.5700 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 32.000000 2411.9600 75.3738
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 16.261067 1219.5800 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.212134 615.9100 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 6.900019 361.4300 52.3810
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 0.907995 46.6800 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 6.571484 337.8400 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 3.010698 154.7800 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 0.756468 38.8900 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 98 205.734132 14902.6900 72.4366
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 9.000000 450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 118.024410 8492.6200 71.9565
OCCT-97530HM-OT SESSION BY OT ASST 25 151.267414 8723.3800 57.6686
PHY-97110-PT SESSION BY LICENSED PT 12 56.278110 4049.2000 71.9498
PHY-97110HM-PT SESSION BY PT ASST 19 116.469422 6704.9092 57.5680
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 330.741007 23807.5700 71.9825
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 116 783.780363 52371.5992 66.8192
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Total 989.514495 67274.2892 67.9872
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Number of Children (Unduplicated) With at Least One Service 182
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Center 55
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 482 492.250000 33624.3200 33624.3200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 42 82.000000 6135.3300 0.0000
T 0 0.000000 0.0000 0.0000
472 415.264495 27514.6392 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 996 989.514495 67274.2892 33624.3200