CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 911 3144.750000 116947.5000 37.1882
Subtotal (Total Children Is Unduplicated) 911 3144.750000 116947.5000 37.1882
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 2.000000 233.6600 116.8300
AACIS-92597TL-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 116.8300 116.8300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 161.9600 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 4 7.500000 607.3500 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 8.000000 647.8400 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 6 11.000000 659.1200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 18.000000 1078.5600 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 485.8800 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 21.500000 1741.0700 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 18 36.000000 2915.2800 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 56.000000 4494.3900 80.2570
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 51 93.500000 7571.6300 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 809.8000 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 18 35.500000 2874.7900 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 80.000000 4793.6000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 71 139.500000 8358.8400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 61.000000 4939.7800 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 27.500000 2226.9500 80.9800
SCREEN-T1023-SCREENING 4 4.000000 215.9200 53.9800
Subtotal (Total Children Is Unduplicated) 204 625.500000 45378.6400 72.5478
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 4 4.000000 191.7600 47.9400
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 143.9200 71.9600
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 20.000000 540.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 371 1463.250000 79069.5000 54.0369
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 107 192.750000 10408.5000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 8.000000 650.5600 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 65.1200 65.1200
OCCT-97530TL-OT SESSION BY LICENSED OT 2 3.000000 243.9600 81.3200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 67 341.000000 27750.4500 81.3796
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 10 24.000000 1951.6800 81.3200
OCCT-97530TLGTHM-OT SESSION BY OT ASST 8 11.000000 716.3200 65.1200
OCCT-97530TLHM-OT SESSION BY OT ASST 19 80.000000 5209.6000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 11 30.000000 2439.6000 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 35 164.500000 13377.1400 81.3200
PHY-97110TLGT-PT SESSION BY LICENSED PT 6 6.250000 508.2500 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 55.000000 4472.6000 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 6.500000 528.5800 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 34 104.500000 8497.9400 81.3200
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 243.9600 81.3200
Subtotal (Total Children Is Unduplicated) 588 2521.750000 157172.0800 62.3266
-----------------------------------------------------------------------------------------------------------------------
Total 6292.000000 319498.2200 50.7785
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 983
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 99 100.000000 4663.6100 0.0000
U 0 0.000000 0.0000 0.0000
B 1929 1851.000000 89445.1100 0.0000
P 2626 2445.250000 122042.0600 121412.9600
D 15 11.000000 707.0100 0.0000
S 129 124.750000 4773.0600 0.0000
H 5 7.000000 394.0800 0.0000
T 5 5.000000 273.5600 0.0000
1512 1603.750000 90144.5100 0.0000
Other 187 144.250000 7055.2200 719.1700
---------------------------------------------------------
Total 6507 6292.000000 319498.2200 122132.1300