CMS/EIP Fiscal Report Center: 02
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
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 86.1700 43.0850
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 3 3.000000 144.2800 48.0933
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 54.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 115.000000 8317.2100 72.3236
OCCT-97530GO-OT SESSION BY LICENSED OT 1 6.250000 508.2500 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 1 2.500000 136.9000 54.7600
PHY-97110-PT SESSION BY LICENSED PT 5 27.500000 2236.3000 81.3200
PHY-97110HM-PT SESSION BY PT ASST 4 4.750000 128.3100 27.0126
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 20 68.750000 4672.0700 67.9574
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 12.750000 633.7200 49.7035
Subtotal (Total Children Is Unduplicated) 40 238.500000 16686.7600 69.9655
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Total 241.500000 16831.0400 69.6937
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Number of Children (Unduplicated) With at Least One Service 41
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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 230 181.750000 12715.8500 12716.1500
93 59.750000 4115.1900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 323 241.500000 16831.0400 12716.1500