CMS/EIP Fiscal Report Center: 05
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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 14.6200 14.6200
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 9 13.000000 807.1200 62.0862
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 111.500000 5785.0000 51.8834
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 5.000000 250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 70.500000 4953.9000 70.2681
PHY-97110-PT SESSION BY LICENSED PT 3 3.750000 295.5900 78.8240
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 6.000000 105.6000 17.6000
Subtotal (Total Children Is Unduplicated) 57 196.750000 11390.0900 57.8912
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Total 209.750000 12197.2100 58.1512
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Number of Children (Unduplicated) With at Least One Service 62
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Center 05
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 205 205.750000 11963.2500 11963.2500
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
4 4.000000 233.9600 233.9600
Other 0 0.000000 0.0000 0.0000
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Total 209 209.750000 12197.2100 12197.2100