CMS/EIP Fiscal Report Center: 02
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 26.0700 26.0700
OCTH-97165-OT EVAL LOW COMPLEXITY 5 5.000000 263.7500 52.7500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 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 5 5.000000 219.5100 43.9020
Subtotal (Total Children Is Unduplicated) 24 38.000000 2416.3800 63.5889
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 632.0000 632.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 1 1.000000 15.0000 15.0000
OCCT-97530-OT SESSION BY LICENSED OT 31 119.000000 8211.0800 69.0007
OCCT-97530GT-OT SESSION BY LICENSED OT 1 12.000000 863.5200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 9 31.000000 2230.7600 71.9600
PHY-97110HM-PT SESSION BY PT ASST 4 15.000000 731.5000 48.7667
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 113.000000 7704.9800 68.1857
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 10.000000 576.0000 57.6000
Subtotal (Total Children Is Unduplicated) 57 307.000000 21214.8400 69.1037
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Total 345.000000 23631.2200 68.4963
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Number of Children (Unduplicated) With at Least One Service 68
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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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 469 344.250000 23600.0600 23469.6200
0 0.000000 0.0000 0.0000
Other 1 0.750000 31.1600 31.1600
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Total 470 345.000000 23631.2200 23500.7800