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
Agency Filter:EIP DEI DEIP
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
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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-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 11.500000 862.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 33.000000 2475.0000 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 9 12.500000 937.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 24.000000 1800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 34 64.000000 3552.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 70.000000 5250.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 30.000000 2250.0000 75.0000
Subtotal (Total Children Is Unduplicated) 156 370.500000 26343.6100 71.1029
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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 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 1 2.000000 143.9200 71.9600
PHY-97110GT-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) 270 1303.720000 83531.7300 64.0718
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Total 4570.970000 217625.1400 47.6103
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Number of Children (Unduplicated) With at Least One Service 821
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Center 54
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 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
0 0.000000 0.0000 0.0000
Other 29 29.250000 2005.8600 224.5500
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Total 4929 4570.970000 217625.1400 212954.7300