CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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 3 6.000000 485.8800 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.500000 629.1600 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 38.000000 3077.2400 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 485.8800 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 24.000000 1943.5200 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 485.8800 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 64.000000 5182.7200 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 971.7600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 72.000000 4314.2400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 12 12.000000 697.3200 58.1100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 348.6600 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 7.000000 406.7700 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 290.5500 58.1100
Subtotal (Total Children Is Unduplicated) 132 285.500000 20367.6700 71.3404
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 206 1463.500000 79029.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 17 48.000000 2592.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 43 224.500000 18256.3400 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 51 456.250000 29711.0000 65.1200
OCCT-97530TLHM-OT SESSION BY OT ASST 1 2.000000 130.2400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 27 155.500000 12645.2600 81.3200
PHY-97110HM-PT SESSION BY PT ASST 20 139.500000 9100.5200 65.2367
PHY-97110HMGT-PT SESSION BY PT ASST 1 1.000000 65.1200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 91 648.500000 52736.0200 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 8.000000 650.5600 81.3200
Subtotal (Total Children Is Unduplicated) 394 3146.750000 204916.0600 65.1199
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Total 3432.250000 225283.7300 65.6373
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Number of Children (Unduplicated) With at Least One Service 451
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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
3358 3432.250000 225283.7300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3358 3432.250000 225283.7300 0.0000