CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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 764 2502.000000 93009.3000 37.1740
Subtotal (Total Children Is Unduplicated) 764 2502.000000 93009.3000 37.1740
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AACIS-92597TLGT-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 116.8300 116.8300
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 485.8800 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 10.000000 809.8000 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 12.000000 971.7600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.000000 719.0400 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 18.000000 1078.5600 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 31.000000 2510.3800 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 2105.4800 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 36.500000 2834.3000 77.6521
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 38 73.000000 5911.5400 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.500000 526.3700 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 22 42.000000 3401.1600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 81.000000 4853.5200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 56 109.000000 6522.4400 59.8389
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 48.000000 3887.0400 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 30.000000 2429.4000 80.9800
SCREEN-T1023-SCREENING 1 1.000000 53.9800 53.9800
Subtotal (Total Children Is Unduplicated) 150 547.000000 39541.4000 72.2878
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 2 2.000000 95.8800 47.9400
AACFIT-92609TL-AAC FITTING, ADJUST, TRAINING VISIT 3 3.000000 143.8200 47.9400
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 40.000000 1107.0000 27.6750
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 417 1961.500000 105944.0000 54.0117
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 161 333.750000 18022.5000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 18.300000 1486.0200 81.2033
OCCT-97530GO-OT SESSION BY LICENSED OT 2 2.000000 162.6400 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 3 5.000000 325.6000 65.1200
OCCT-97530TL-OT SESSION BY LICENSED OT 3 6.750000 569.2400 84.3319
OCCT-97530TLGO-OT SESSION BY LICENSED OT 78 345.250000 28047.5700 81.2384
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 13 17.750000 1443.4300 81.3200
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530TLGTHM-OT SESSION BY OT ASST 6 8.000000 520.9600 65.1200
OCCT-97530TLHM-OT SESSION BY OT ASST 16 61.000000 3972.3200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 17 71.130000 5784.1900 81.3186
PHY-97110GT-PT SESSION BY LICENSED PT 3 2.130000 173.1100 81.2723
PHY-97110TL-PT SESSION BY LICENSED PT 38 177.750000 14454.6300 81.3200
PHY-97110TLGT-PT SESSION BY LICENSED PT 8 10.000000 813.2000 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 119.000000 9677.0800 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 20.000000 1626.4000 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 33 105.500000 8579.2600 81.3200
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 8 12.750000 1036.8300 81.3200
Subtotal (Total Children Is Unduplicated) 650 3324.560000 204148.3200 61.4061
-----------------------------------------------------------------------------------------------------------------------
Total 6373.560000 336699.0200 52.8275
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 844
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 153 152.500000 7327.3600 74.4200
P 4090 3711.500000 184208.0000 182786.8500
D 14 14.000000 1094.3600 431.7600
S 18 13.560000 1083.4800 0.0000
H 9 9.000000 731.8800 0.0000
T 0 0.000000 0.0000 0.0000
2298 2396.250000 137172.1400 0.0000
Other 78 76.750000 5081.8000 2045.0600
---------------------------------------------------------
Total 6660 6373.560000 336699.0200 185338.0900