CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2025 ending 03/31/2025 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
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 4 5.500000 325.9400 59.2618
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 28 70.000000 3780.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 1 3.000000 243.9600 81.3200
Subtotal (Total Children Is Unduplicated) 29 75.000000 4186.6000 55.8213
-----------------------------------------------------------------------------------------------------------------------
Total 80.500000 4512.5400 56.0564
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 31
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 1 1.000000 54.0000 54.0000
D 76 77.500000 4350.5400 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
2 2.000000 108.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 79 80.500000 4512.5400 54.0000