CMS/EIP Fiscal Report Center: 55
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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 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 5 10.000000 555.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 52.000000 3900.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 46.000000 3400.0000 73.9130
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 54.000000 4050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 14.000000 1061.9600 75.8543
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 56.000000 3108.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 321.8600 53.6433
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 726.4400 51.8886
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 6 6.000000 308.4600 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 565.5100 51.4100
Subtotal (Total Children Is Unduplicated) 142 315.000000 21078.3900 66.9155
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 189 1411.750000 70667.5000 50.0567
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 21.000000 1054.0000 50.1905
OCCT-97530-OT SESSION BY LICENSED OT 40 211.500000 15207.3600 71.9024
OCCT-97530HM-OT SESSION BY OT ASST 57 490.500000 28279.1200 57.6537
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 30 191.000000 13744.3600 71.9600
PHY-97110HM-PT SESSION BY PT ASST 30 202.250000 11684.7100 57.7736
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 108 732.250000 52786.3100 72.0878
Subtotal (Total Children Is Unduplicated) 401 3261.250000 193480.9600 59.3272
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Total 3576.250000 214559.3500 59.9956
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Number of Children (Unduplicated) With at Least One Service 457
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Center 55
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
3477 3576.250000 214559.3500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3477 3576.250000 214559.3500 0.0000