CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:LEA
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 1 1.000000 58.1100 58.1100
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 100 2197.000000 59319.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 16.000000 864.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 45.000000 3659.4000 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 31 115.000000 7488.8000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 31 86.000000 6993.5200 81.3200
PHY-97110HM-PT SESSION BY PT ASST 18 32.000000 2083.8400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 183.500000 14922.2200 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 12 52.500000 3418.8000 65.1200
Subtotal (Total Children Is Unduplicated) 103 2727.000000 98749.5800 36.2118
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Total 2728.000000 98807.6900 36.2198
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Number of Children (Unduplicated) With at Least One Service 103
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Center 04
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 0 0.000000 0.0000 0.0000
1986 2728.000000 98807.6900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1986 2728.000000 98807.6900 0.0000