CMS/EIP Fiscal Report Center: 55
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
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 8 16.000000 958.7200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 22.000000 1781.5600 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 48.000000 3887.0400 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 13 26.000000 2105.4800 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 485.8800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 26.000000 1557.9200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 359.5200 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 116.2200 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 6.000000 348.6600 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 174.3300 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 83 181.000000 13261.3300 73.2670
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 171 613.000000 33102.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 30.500000 1647.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 31 143.500000 11669.4200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 47 213.750000 13919.4000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 21 105.000000 8538.6000 81.3200
PHY-97110HM-PT SESSION BY PT ASST 25 107.750000 7032.9600 65.2711
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 80 298.000000 24233.3600 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 162.6400 81.3200
Subtotal (Total Children Is Unduplicated) 340 1513.500000 100305.3800 66.2738
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Total 1694.500000 113566.7100 67.0208
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Number of Children (Unduplicated) With at Least One Service 398
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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
1639 1694.500000 113566.7100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1639 1694.500000 113566.7100 0.0000