CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
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 1.500000 121.4700 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 2.500000 202.4500 80.9800
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 202.4500 80.9800
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 12.000000 920.9300 76.7442
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 1824.0000 304.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 13 31.500000 3800.3400 120.6457
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 7.500000 609.9000 81.3200
Subtotal (Total Children Is Unduplicated) 1 7.500000 609.9000 81.3200
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Total 39.000000 4410.2400 113.0831
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Number of Children (Unduplicated) With at Least One Service 13
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Center 04
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 21 16.000000 2152.1500 1428.2300
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
16 22.000000 2176.7700 0.0000
Other 2 1.000000 81.3200 0.0000
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Total 39 39.000000 4410.2400 1428.2300