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
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 764 2502.000000 93009.3000 37.1740
Subtotal (Total Children Is Unduplicated) 764 2502.000000 93009.3000 37.1740
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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 1 2.000000 161.9600 80.9800
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 10.000000 599.2000 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 17.000000 1376.6600 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 11 22.000000 1781.5600 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 37 71.000000 5749.5800 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 364.4100 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 18.000000 1457.6400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 10.500000 629.1600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 28 55.000000 3286.7600 59.7593
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 28.000000 2267.4400 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 22.000000 1781.5600 80.9800
SCREEN-T1023-SCREENING 1 1.000000 53.9800 53.9800
Subtotal (Total Children Is Unduplicated) 130 318.500000 24080.6400 75.6064
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 85 306.500000 16578.0000 54.0881
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 32 70.000000 3780.0000 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 2 3.130000 254.4300 81.2875
PHY-97110GT-PT SESSION BY LICENSED PT 1 0.130000 10.4700 80.5385
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-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) 272 1156.810000 82436.9400 71.2623
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Total 3977.310000 199526.8800 50.1663
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Number of Children (Unduplicated) With at Least One Service 783
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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 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
0 0.000000 0.0000 0.0000
Other 78 76.750000 5081.8000 2045.0600
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Total 4362 3977.310000 199526.8800 185338.0900