CMS/EIP Fiscal Report Center: 57
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 2 3.500000 283.4300 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 242.9400 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.500000 389.4800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.500000 607.3500 80.9800
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 3 4.500000 364.4100 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 13.000000 778.9600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 4.000000 232.4400 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 116.2200 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 174.3300 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 20 53.000000 3587.5800 67.6902
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 45.000000 2430.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 51.000007 4147.3200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 2 27.000006 1758.2400 65.1200
PHY-97110HM-PT SESSION BY PT ASST 1 0.500000 32.5600 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 162.6400 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.500000 121.9800 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.500000 97.6800 65.1200
Subtotal (Total Children Is Unduplicated) 15 128.500013 8750.4200 68.0966
-----------------------------------------------------------------------------------------------------------------------
Total 181.500013 12338.0000 67.9780
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 34
-----------------------------------------------------------------------------------------------------------------------
Center 57
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 0 0.000000 0.0000 0.0000
D 4 4.000000 325.2800 0.0000
S 0 0.000000 0.0000 0.0000
H 23 40.000000 2828.5300 2828.5300
T 45 30.793509 2227.7800 2227.7800
124 106.706504 6956.4100 505.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 196 181.500013 12338.0000 5561.3100