CMS/EIP Fiscal Report Center: 55
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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 239.6800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 485.8800 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 809.8000 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 359.5200 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 406.7700 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 174.3300 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 27 51.000000 3576.3300 70.1241
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 99 634.750000 34276.5000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 12.750000 688.5000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 100.000000 8132.0000 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 39 267.250000 17403.3200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 20 109.750000 8924.8700 81.3200
PHY-97110HM-PT SESSION BY PT ASST 22 122.750000 7993.4800 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 45 194.500000 15816.7400 81.3200
Subtotal (Total Children Is Unduplicated) 211 1441.750000 93235.4100 64.6682
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Total 1492.750000 96811.7400 64.8546
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Number of Children (Unduplicated) With at Least One Service 221
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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
1506 1492.750000 96811.7400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1506 1492.750000 96811.7400 0.0000