CMS/EIP Fiscal Report Center: 54
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 882 3375.500000 125559.3000 37.1972
Subtotal (Total Children Is Unduplicated) 882 3375.500000 125559.3000 37.1972
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AACIS-92597TL-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 103.3600 103.3600
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 13.500000 1012.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 23 44.500000 3337.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 38.500000 2887.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 49 90.600000 6795.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 15.500000 1162.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 29.000000 2175.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 47 89.500000 4967.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 98.000000 7350.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 33.500000 2512.5000 75.0000
Subtotal (Total Children Is Unduplicated) 214 493.100000 34934.1100 70.8459
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 42.4100 42.4100
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 87 359.000000 17950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 40 102.000000 5100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 3.000000 215.8800 71.9600
OCCT-97530GO-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 3 8.000000 460.8000 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 62 216.750000 15597.3300 71.9600
OCCT-97530TLGO-OT SESSION BY LICENSED OT 75 200.000000 14392.0000 71.9600
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 17 19.000000 1367.2400 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 10 14.000000 1007.4400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 41 195.750000 14086.1700 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 11 16.000000 1151.3600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 27 102.000000 7339.9200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 11 25.500000 1834.9800 71.9600
Subtotal (Total Children Is Unduplicated) 264 1268.000000 80962.9300 63.8509
-----------------------------------------------------------------------------------------------------------------------
Total 5136.600000 241456.3400 47.0070
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 909
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 32 30.250000 1681.4600 0.0000
P 5363 5106.350000 239774.8800 239726.1300
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5395 5136.600000 241456.3400 239726.1300