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:Part C (excluding not eligible)
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 6 8.000000 647.8400 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 17 22.000000 1769.6000 80.4364
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 5.500000 445.3900 80.9800
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.500000 526.3700 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 8 10.000000 809.8000 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.500000 196.4700 78.5880
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.000000 617.9400 77.2425
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.500000 817.4000 77.8476
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 49.000000 3697.3000 75.4551
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 304.0000 304.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 3040.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 109.5200 54.7600
OCTH-97165-OT EVAL LOW COMPLEXITY 33 40.000000 2206.4500 55.1613
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 21 29.000000 1537.3400 53.0117
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 212.3400 53.0850
SPCH-92521-EVAL OF SPEECH FLUENCY 36 46.000000 2518.9600 54.7600
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 125 265.000000 20186.1400 76.1741
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 10.000000 540.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 42 422.500000 32382.6500 76.6453
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 11 120.000000 7513.6000 62.6133
PHY-97110-PT SESSION BY LICENSED PT 33 309.000000 24252.4800 78.4870
PHY-97110HM-PT SESSION BY PT ASST 10 65.000000 3911.5000 60.1769
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 520.500000 40955.8200 78.6855
Subtotal (Total Children Is Unduplicated) 94 1448.000000 109628.0100 75.7100
-----------------------------------------------------------------------------------------------------------------------
Total 1713.000000 129814.1500 75.7818
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 144
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 1576 918.000000 68071.3800 28806.4300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 38 38.000000 2670.5600 0.0000
T 0 0.000000 0.0000 0.0000
81 110.000000 10301.0200 0.0000
Other 1075 647.000000 48771.1900 0.0000
---------------------------------------------------------
Total 2770 1713.000000 129814.1500 28806.4300