CMS/EIP Fiscal Report Center: 54
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 40 74.500000 4145.8000 55.6483
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 54 104.500000 5830.6900 55.7961
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.500000 862.5000 82.1429
Subtotal (Total Children Is Unduplicated) 120 248.000000 14972.9900 60.3750
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 58.000000 1450.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 329 1845.750000 92169.5000 49.9361
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 118 207.000000 10382.0000 50.1546
PHY-97110-PT SESSION BY LICENSED PT 18 97.000000 6980.1200 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 3 3.000000 215.8800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 96.000000 6908.1600 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 9.000000 647.6400 71.9600
Subtotal (Total Children Is Unduplicated) 388 2315.750000 118753.3000 51.2807
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Total 2563.750000 133726.2900 52.1604
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Number of Children (Unduplicated) With at Least One Service 464
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Center 54
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
2454 2563.750000 133726.2900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2454 2563.750000 133726.2900 0.0000