CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2025 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
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 2 3.000000 220.0700 73.3567
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 58.000000 3132.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 54.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 3.000000 243.9600 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 1 3.000000 243.9600 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 162.6400 81.3200
Subtotal (Total Children Is Unduplicated) 17 67.000000 3836.5600 57.2621
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Total 70.000000 4056.6300 57.9519
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Number of Children (Unduplicated) With at Least One Service 18
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Center 01
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 67 68.000000 3893.9900 0.0000
S 0 0.000000 0.0000 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
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Total 69 70.000000 4056.6300 162.6400