CMS/EIP Fiscal Report Center: 51
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
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 80.9800 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 5.500000 445.3900 80.9800
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 6.500000 526.3700 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 10 17.500000 1348.5400 77.0594
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 49 283.000000 15282.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 270.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 66.000000 5367.1200 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 5 57.000000 3711.8400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 11 60.000000 4879.2000 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 84.000000 6830.8800 81.3200
Subtotal (Total Children Is Unduplicated) 76 556.000000 36422.3600 65.5078
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Total 573.500000 37770.9000 65.8603
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Number of Children (Unduplicated) With at Least One Service 82
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Center 51
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
587 573.500000 37770.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 587 573.500000 37770.9000 0.0000