CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2025 ending 03/31/2025 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 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 107.2800 53.6400
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 207.0900 41.4180
Subtotal (Total Children Is Unduplicated) 14 17.000000 1032.6900 60.7465
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 40.6600 20.3300
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 54.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 1 2.000000 30.0000 15.0000
OCCT-97530-OT SESSION BY LICENSED OT 36 157.750000 12658.3300 80.2430
OCCT-97530HM-OT SESSION BY OT ASST 2 2.500000 162.8000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 11 35.000000 2942.9000 84.0829
PHY-97110HM-PT SESSION BY PT ASST 4 11.750000 524.3200 44.6230
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 146.750000 11541.8900 78.6500
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 19.000000 1188.1400 62.5337
Subtotal (Total Children Is Unduplicated) 72 377.750000 29143.0400 77.1490
-----------------------------------------------------------------------------------------------------------------------
Total 394.750000 30175.7300 76.4426
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 77
-----------------------------------------------------------------------------------------------------------------------
Center 02
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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 457 335.750000 25398.1800 25380.8300
75 59.000000 4777.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 532 394.750000 30175.7300 25380.8300