CMS/EIP Fiscal Report Center: 51
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Payclass Filters:MED
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 1.000000 80.9800 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 80.9800 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 28.000000 2198.3500 78.5125
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.500000 114.5000 45.8000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 56.000000 4351.1200 77.6986
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.500000 277.4500 79.2714
OCTH-97165-OT EVAL LOW COMPLEXITY 14 19.000000 1037.0900 54.5837
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 174.3300 58.1100
Subtotal (Total Children Is Unduplicated) 79 120.000000 8674.6600 72.2888
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 147 2186.500000 115128.9600 52.6545
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 11.000000 590.0000 53.6364
OCCT-97530-OT SESSION BY LICENSED OT 76 600.000000 47519.9200 79.1999
OCCT-97530GO-OT SESSION BY LICENSED OT 2 3.000000 243.9600 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 6 21.750000 1583.8500 72.8207
OCCT-97530HM-OT SESSION BY OT ASST 21 489.000000 30414.8000 62.1980
OCCT-97530HMGT-OT SESSION BY OT ASST 4 6.000000 353.1200 58.8533
OCCT-97530TL-OT SESSION BY LICENSED OT 1 8.000000 650.5600 81.3200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TLHM-OT SESSION BY OT ASST 9 51.000000 3283.5200 64.3827
PHY-97110-PT SESSION BY LICENSED PT 26 336.000000 26658.9600 79.3421
PHY-97110TL-PT SESSION BY LICENSED PT 1 6.000000 431.7600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 110 1032.750000 80864.5300 78.3002
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 10.000000 738.3200 73.8320
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 6.000000 459.8400 76.6400
Subtotal (Total Children Is Unduplicated) 296 4768.000000 308994.0600 64.8058
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Total 4888.000000 317668.7200 64.9895
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Number of Children (Unduplicated) With at Least One Service 327
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Center 51
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 0 0.000000 0.0000 0.0000
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
4926 4888.000000 317668.7200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4926 4888.000000 317668.7200 0.0000