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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
Subtotal (Total Children Is Unduplicated) 1 1.000000 80.9800 80.9800
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
PHY-97110-PT SESSION BY LICENSED PT 3 7.750000 648.5700 83.6865
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 406.6000 81.3200
Subtotal (Total Children Is Unduplicated) 5 13.750000 1136.4900 82.6538
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Total 14.750000 1217.4700 82.5403
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Number of Children (Unduplicated) With at Least One Service 6
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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 5 3.750000 323.2900 323.2900
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
11 11.000000 894.1800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16 14.750000 1217.4700 323.2900