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: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 7 9.500000 769.3100 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 19 24.500000 1972.0500 80.4918
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 5 8.500000 688.3300 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 9 11.500000 931.2700 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 5 7.000000 539.9500 77.1357
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 13.000000 1004.9000 77.3000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 61.000000 4618.2300 75.7087
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 304.0000 304.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.000000 4864.0000 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 37 47.000000 2577.0700 54.8313
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) 138 296.500000 23986.4800 80.8988
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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 45 528.000000 41565.7200 78.7230
Subtotal (Total Children Is Unduplicated) 95 1455.500000 110237.9100 75.7389
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Total 1752.000000 134224.3900 76.6121
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Number of Children (Unduplicated) With at Least One Service 157
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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 1597 934.000000 70223.5300 30234.6600
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
97 132.000000 12477.7900 0.0000
Other 1077 648.000000 48852.5100 0.0000
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Total 2809 1752.000000 134224.3900 30234.6600