CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2025 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 4 5.500000 445.3900 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 6.500000 526.3700 80.9800
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 1 1.000000 80.9800 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 4 5.000000 404.9000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 4.000000 323.9200 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 304.0000 304.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 5 5.000000 290.5500 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 156.8800 52.2933
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 19 42.000000 3400.9000 80.9738
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 11 33.500000 2724.2200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 3 22.000000 1432.6400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 5 27.000000 2195.6400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 1 1.500000 97.6800 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 66.000000 5367.1200 81.3200
Subtotal (Total Children Is Unduplicated) 26 150.000000 11817.3000 78.7820
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Total 192.000000 15218.2000 79.2615
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Number of Children (Unduplicated) With at Least One Service 36
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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 24 16.500000 1171.6800 1171.6800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 4.000000 260.4800 0.0000
T 0 0.000000 0.0000 0.0000
23 33.000000 2895.3600 0.0000
Other 256 138.500000 10890.6800 0.0000
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Total 307 192.000000 15218.2000 1171.6800