CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2023 ending 06/30/2024 Date of Report:04/12/2025 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1500 7921.500000 294298.4500 37.1519
Subtotal (Total Children Is Unduplicated) 1500 7921.500000 294298.4500 37.1519
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Screening, Eval, and Assessment,Class #02
AACIS-92597TL-AAC INTIAL EVAL BY LICENSED SLP 2 2.000000 206.7200 103.3600
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 31.000000 2325.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 25 44.000000 3300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 16 29.500000 2212.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 9.500000 712.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 10 18.000000 1350.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 42 81.500000 4523.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 75 137.500000 10312.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 287 492.500000 36900.0000 74.9239
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 66.530000 4989.5700 74.9973
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 229 414.500000 31050.0000 74.9095
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 44.500000 3337.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 144 243.500000 18233.2500 74.8799
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 92.000000 5145.0000 55.9239
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 513 909.500000 50538.5000 55.5673
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 64.000000 4800.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 57 107.500000 8061.0000 74.9860
SPCH-92521TLGT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92610TL-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 11.000000 565.5100 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 8 80.000000 4112.8000 51.4100
Subtotal (Total Children Is Unduplicated) 834 2891.530000 193486.4200 66.9149
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 42.4100 42.4100
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 565 5474.500000 273725.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 367 1391.000000 69537.5000 49.9910
OCCT-97530-OT SESSION BY LICENSED OT 69 581.000000 41786.8000 71.9222
OCCT-97530GO-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 35 89.500000 6440.4200 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 95 676.500000 48680.9400 71.9600
OCCT-97530TLGO-OT SESSION BY LICENSED OT 6 15.500000 1115.3800 71.9600
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 4 17.000000 1223.3200 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 47 155.500000 11153.8000 71.7286
PHY-97110-PT SESSION BY LICENSED PT 6 44.750000 3220.2100 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 3 4.500000 323.8200 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 81 1049.040000 75524.5800 71.9940
PHY-97110TLGT-PT SESSION BY LICENSED PT 27 40.750000 2932.3700 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 277.540000 19971.1000 71.9576
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 22 38.500000 2770.4600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 142 1135.130000 81682.7500 71.9589
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 64 194.230000 13976.4100 71.9580
Subtotal (Total Children Is Unduplicated) 963 11187.94000 654204.2300 58.4741
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Total 22000.970000 1141989.1000 51.9063
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Number of Children (Unduplicated) With at Least One Service 1580
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Center 53
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 11 12.000000 604.3200 0.0000
P 16128 15475.110000 777869.0200 777500.8100
D 0 0.000000 0.0000 0.0000
S 8 9.230000 679.1700 0.0000
H 24 15.750000 585.9000 0.0000
T 0 0.000000 0.0000 0.0000
6128 6427.000000 357983.6300 0.0000
Other 71 61.880000 4267.0600 50.0000
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Total 22370 22000.970000 1141989.1000 777550.8100