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:TPIN
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-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.114267 608.5700 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 10.163200 762.2400 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.114267 608.5700 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 6.900019 361.4300 52.3810
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 0.907995 46.6800 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 6.571484 337.8400 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 3.010698 154.7800 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 0.756468 38.8900 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 36 54.538398 3574.6400 65.5435
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 9.000000 450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 118.024410 8492.6200 71.9565
OCCT-97530HM-OT SESSION BY OT ASST 25 151.267414 8723.3800 57.6686
PHY-97110-PT SESSION BY LICENSED PT 12 56.278110 4049.2000 71.9498
PHY-97110HM-PT SESSION BY PT ASST 19 116.469422 6704.9092 57.5680
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 47 287.625385 20704.9700 71.9859
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 110 739.664741 49197.0392 66.5126
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Total 794.203139 52771.6792 66.4461
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Number of Children (Unduplicated) With at Least One Service 121
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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 478 484.250000 33024.3200 33024.3200
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
394 309.953139 19747.3592 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 872 794.203139 52771.6792 33024.3200