CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2025 ending 03/31/2025 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 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 16.500000 1336.1700 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 28.000000 2137.0500 76.3232
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 25 53.500000 4045.5700 75.6181
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 8.000000 432.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 16.000000 1301.1200 81.3200
PHY-97110-PT SESSION BY LICENSED PT 11 18.000000 1396.7400 77.5967
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 23 77.000000 5928.8700 76.9983
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
Subtotal (Total Children Is Unduplicated) 44 120.000000 9140.0500 76.1671
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Total 173.500000 13185.6200 75.9978
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Number of Children (Unduplicated) With at Least One Service 66
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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 11 11.000000 894.5200 894.5200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 14 14.000000 1111.1600 1111.1600
T 0 0.000000 0.0000 0.0000
126 148.500000 11179.9400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 151 173.500000 13185.6200 2005.6800