CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 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 2 4.000000 283.9200 70.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 647.8400 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 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 32.2400 32.2400
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 15 23.000000 1636.5800 71.1557
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 4035.3000 4035.3000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 9.000000 486.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 85.500000 6609.3000 77.3018
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 1 0.750000 48.8400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 8 11.500000 895.5900 77.8774
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
PHY-97110HM-PT SESSION BY PT ASST 3 2.000000 67.2600 33.6300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 50.750000 3538.3500 69.7212
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 5.000000 325.6000 65.1200
Subtotal (Total Children Is Unduplicated) 45 169.500000 16331.5200 96.3512
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Total 192.500000 17968.1000 93.3408
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Number of Children (Unduplicated) With at Least One Service 55
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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 211 186.500000 17553.7600 17553.7400
6 6.000000 414.3400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 217 192.500000 17968.1000 17553.7400