CMS/EIP Fiscal Report Center: 57
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 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
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 311.000000 8397.0000 27.0000
OCCT-97530HM-OT SESSION BY OT ASST 7 17.500000 1139.6000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 6 14.000000 1138.4800 81.3200
PHY-97110HM-PT SESSION BY PT ASST 7 15.000000 976.8000 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 22.500000 1829.7000 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 4.000000 260.4800 65.1200
Subtotal (Total Children Is Unduplicated) 16 384.000000 13742.0600 35.7866
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Total 384.000000 13742.0600 35.7866
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Number of Children (Unduplicated) With at Least One Service 16
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Center 57
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
458 384.000000 13742.0600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 458 384.000000 13742.0600 0.0000