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
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 793 2896.750000 107749.8000 37.1968
Subtotal (Total Children Is Unduplicated) 793 2896.750000 107749.8000 37.1968
-----------------------------------------------------------------------------------------------------------------------
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 2 4.000000 300.0000 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 4 7.500000 562.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 17.000000 943.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 25.500000 1912.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 19 37.000000 2775.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 25.500000 1912.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 38 71.000000 5325.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 16.500000 1237.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 19 37.500000 2812.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 80.000000 4451.0500 55.6381
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 88 168.500000 9382.6900 55.6836
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 76.000000 5700.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 40.500000 3112.5000 76.8519
Subtotal (Total Children Is Unduplicated) 172 618.500000 41316.6000 66.8013
-----------------------------------------------------------------------------------------------------------------------
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 7 58.000000 1450.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 413 2204.750000 110119.5000 49.9465
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 156 309.000000 15482.0000 50.1036
OCCT-97530-OT SESSION BY LICENSED OT 7 22.710000 1633.2100 71.9159
OCCT-97530GO-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 1.750000 125.9300 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 64 218.750000 15741.2500 71.9600
OCCT-97530TLGO-OT SESSION BY LICENSED OT 76 211.000000 15183.5600 71.9600
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 18 19.260000 1385.3400 71.9283
OCCT-97530TLGT-OT SESSION BY LICENSED OT 10 14.000000 1007.4400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 19 99.000000 7124.0400 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 4 4.000000 287.8400 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 17 97.000000 6980.1200 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 9.000000 647.6400 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) 644 3619.470000 202285.0300 55.8880
-----------------------------------------------------------------------------------------------------------------------
Total 7134.720000 351351.4300 49.2453
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 864
-----------------------------------------------------------------------------------------------------------------------
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 4849 4492.750000 212580.1800 212580.1800
D 4 5.000000 365.8800 150.0000
S 5 6.000000 437.8400 0.0000
H 10 7.720000 553.9200 0.0000
T 0 0.000000 0.0000 0.0000
2454 2563.750000 133726.2900 0.0000
Other 29 29.250000 2005.8600 224.5500
---------------------------------------------------------
Total 7383 7134.720000 351351.4300 212954.7300