CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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 3 6.000000 485.8800 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 43.4500 28.9667
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 179.7600 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 85.000000 6407.3600 75.3807
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 62 116.000000 9043.9200 77.9648
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 378.9600 47.3700
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 25.000000 1498.0000 59.9200
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 232.4400 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 126.3700 42.1233
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 174.3300 58.1100
Subtotal (Total Children Is Unduplicated) 112 260.500000 18964.8700 72.8018
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 8.000000 432.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 54.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 50.500000 3190.6300 63.1808
PHY-97110-PT SESSION BY LICENSED PT 24 117.250000 8543.3400 72.8643
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 161.750000 11661.3000 72.0946
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
Subtotal (Total Children Is Unduplicated) 83 339.500000 23962.5900 70.5820
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Total 600.000000 42927.4600 71.5458
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Number of Children (Unduplicated) With at Least One Service 178
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Center 03
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 362 458.500000 32643.2100 32643.2100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 29 29.000000 2219.9000 2219.9000
T 0 0.000000 0.0000 0.0000
96 112.500000 8064.3500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 487 600.000000 42927.4600 34863.1100