CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
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) 6 8.500000 569.5400 67.0047
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 108 377.000000 19638.0000 52.0902
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 12 17.000000 866.0000 50.9412
OCCT-97530-OT SESSION BY LICENSED OT 5 13.000000 991.6400 76.2800
OCCT-97530GT-OT SESSION BY LICENSED OT 2 7.000000 569.2400 81.3200
PHY-97110-PT SESSION BY LICENSED PT 2 3.000000 243.9600 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 38.000000 2846.8000 74.9158
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
Subtotal (Total Children Is Unduplicated) 144 456.000000 25236.9600 55.3442
-----------------------------------------------------------------------------------------------------------------------
Total 464.500000 25806.5000 55.5576
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 147
-----------------------------------------------------------------------------------------------------------------------
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 6 6.000000 304.0000 304.0000
D 453 455.500000 25285.8600 0.0000
S 1 1.000000 54.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 2.000000 162.6400 162.6400
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 462 464.500000 25806.5000 466.6400