CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 80.9800 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 6.000000 359.5200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 29.000000 2429.7400 83.7841
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 80.9800 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.000000 323.9200 80.9800
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 33.000000 2672.3400 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 80.9800 80.9800
OCTH-97165-OT EVAL LOW COMPLEXITY 7 7.000000 406.7700 58.1100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 59 86.000000 6667.6700 77.5310
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 119 788.500000 42579.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 108.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 65 246.000000 20004.7200 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 14 171.000000 11135.5200 65.1200
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 65.1200 65.1200
OCCT-97530TL-OT SESSION BY LICENSED OT 1 4.000000 325.2800 81.3200
OCCT-97530TLHM-OT SESSION BY OT ASST 1 9.000000 586.0800 65.1200
PHY-97110-PT SESSION BY LICENSED PT 23 123.000000 10002.3600 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 99 381.000000 30982.9200 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 162.6400 81.3200
Subtotal (Total Children Is Unduplicated) 269 1730.500000 116195.6000 67.1457
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Total 1816.500000 122863.2700 67.6374
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Number of Children (Unduplicated) With at Least One Service 300
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Center 51
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 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
1817 1816.500000 122863.2700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1817 1816.500000 122863.2700 0.0000