CMS/EIP Fiscal Report Center: 55
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 25 49.000000 3896.2600 79.5155
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 785.8800 78.5880
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 485.8800 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 119.8400 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 56 110.114267 8437.9700 76.6292
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 20.000000 1535.8800 76.7940
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1073.9200 76.7086
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.114267 458.5700 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 31 33.527450 1908.7500 56.9310
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 3.907995 221.0100 56.5533
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 8.571484 512.1700 59.7528
PSTF-97164-PT RE-EVAL EST PLAN CARE 17 16.365887 930.8500 56.8775
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 1.831842 101.3800 55.3432
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 109.5200 54.7600
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 13 13.490105 763.8100 56.6200
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 148 305.923297 22017.0200 71.9691
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 37.000000 1962.0000 53.0270
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 3.000000 162.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 48 425.244392 33475.7500 78.7212
OCCT-97530GT-OT SESSION BY LICENSED OT 1 4.000000 325.2800 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 44 633.524941 40127.9900 63.3408
PHY-97110-PT SESSION BY LICENSED PT 28 257.049382 20385.2800 79.3049
PHY-97110HM-PT SESSION BY PT ASST 25 392.944219 24708.9492 62.8816
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 87 1085.051500 85260.4200 78.5773
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 23.500000 1892.3000 80.5234
Subtotal (Total Children Is Unduplicated) 182 2861.314434 208299.9692 72.7987
-----------------------------------------------------------------------------------------------------------------------
Total 3167.237731 230316.9892 72.7186
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 251
-----------------------------------------------------------------------------------------------------------------------
Center 55
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 1763 1704.298192 124387.0200 124387.0200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 65 109.000000 8508.3600 0.0000
T 84 80.250000 5566.3900 5566.3900
1525 1273.689539 91855.2192 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3437 3167.237731 230316.9892 129953.4100