CMS/EIP Fiscal Report Center: 55
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: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 14.000000 1133.7200 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
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 3 6.000000 485.8800 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 406.7700 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 4.000000 232.4400 58.1100
Subtotal (Total Children Is Unduplicated) 25 41.000000 3022.8700 73.7285
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 216.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 63.715196 5181.3200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 18 85.444104 5564.1200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 12 64.036768 5207.4700 81.3200
PHY-97110HM-PT SESSION BY PT ASST 14 58.056200 3780.6200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 175.076243 14237.2000 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 12.500000 1016.5000 81.3200
Subtotal (Total Children Is Unduplicated) 82 462.828511 35203.2300 76.0611
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Total 503.828511 38226.1000 75.8713
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Number of Children (Unduplicated) With at Least One Service 95
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Center 55
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 166 162.750000 12219.7500 12219.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 20.000000 1619.6000 0.0000
T 62 58.250000 4133.7500 4133.7500
288 262.828511 20253.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 526 503.828511 38226.1000 16353.5000