CMS/EIP Fiscal Report Center: 55
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 6 12.000000 923.9200 76.9933
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.000000 761.9600 76.1960
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 311.9600 77.9900
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 28.000000 2195.6800 78.4171
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 311.9600 77.9900
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 23 42.500000 2502.4000 58.8800
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 12.000000 701.3600 58.4467
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 54.000000 4121.7600 76.3289
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 311.9600 77.9900
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 42.000000 3197.8400 76.1390
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 50.000000 3845.6800 76.9136
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 14.000000 1085.8800 77.5629
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 62.000000 3555.9200 57.3535
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 452.8400 56.6050
OCTF-97168-OT RE-EVAL EST PLAN CARE 27 30.000000 1716.5000 57.2167
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 174.3300 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 160.9300 53.6433
OCTH-97167-OT EVAL HIGH COMPLEXITY 22 22.000000 1191.3200 54.1509
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 16 17.000000 967.7700 56.9276
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 8 8.000000 431.3800 53.9225
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 22 22.000000 1204.7200 54.7600
Subtotal (Total Children Is Unduplicated) 212 460.500000 30742.5400 66.7590
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 233 4298.500000 226508.0000 52.6947
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 24 89.250000 4739.5000 53.1036
OCCT-97530-OT SESSION BY LICENSED OT 60 762.500000 59986.6000 78.6710
OCCT-97530HM-OT SESSION BY OT ASST 82 1602.500000 100722.6400 62.8534
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 1 2.000000 130.2400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 41 611.000000 47898.7600 78.3940
PHY-97110HM-PT SESSION BY PT ASST 42 618.250000 38822.3100 62.7939
PHY-97110HMGT-PT SESSION BY PT ASST 1 1.000000 65.1200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 130 1872.000000 145573.7400 77.7638
Subtotal (Total Children Is Unduplicated) 480 9858.000000 624504.5100 63.3500
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Total 10318.500000 655247.0500 63.5022
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Number of Children (Unduplicated) With at Least One Service 532
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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
10304 10318.500000 655247.0500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10304 10318.500000 655247.0500 0.0000