CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2024 ending 03/31/2024 Date of Report:04/04/2025 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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 390.8800 39.0880
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
Subtotal (Total Children Is Unduplicated) 29 52.000000 3345.6100 64.3387
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 6310.4000 3155.2000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 12.000000 600.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 100.250000 7072.6600 70.5502
OCCT-97530GT-OT SESSION BY LICENSED OT 2 11.000000 791.5600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 21 78.500000 5387.2300 68.6271
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 235.750000 16285.6900 69.0803
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 359.8000 71.9600
Subtotal (Total Children Is Unduplicated) 64 445.500000 36857.3400 82.7325
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Total 497.500000 40202.9500 80.8099
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Number of Children (Unduplicated) With at Least One Service 78
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Center 02
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 5 3.250000 -213.3200 213.3200
H 0 0.000000 0.0000 0.0000
T 702 493.250000 40344.3100 40045.2700
0 0.000000 0.0000 0.0000
Other 2 1.000000 71.9600 71.8800
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Total 709 497.500000 40202.9500 40330.4700