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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 6 6.750000 251.1000 37.2000
Subtotal (Total Children Is Unduplicated) 6 7.000000 260.4000 37.2000
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Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 116.8300 116.8300
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 283.4300 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 445.3900 80.9800
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 329.5600 59.9200
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 17.500000 1417.1500 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 42.500000 3441.6500 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 29.000000 2348.4200 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 809.8000 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 20.500000 1228.3600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 13 24.000000 1438.0800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 485.8800 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 242.9400 80.9800
SCREEN-T1023-SCREENING 1 2.000000 107.9600 53.9800
Subtotal (Total Children Is Unduplicated) 71 176.000000 13181.3300 74.8939
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 47.9400 47.9400
ASST-ASST-ASSISTIVE TECHNOLOGY 10 17.000000 1239.6900 72.9229
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 81 285.500000 15417.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 30 49.000000 2646.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 24 92.000000 7481.4400 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 12 44.000000 3578.0800 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 8 10.000000 813.2000 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 4 4.500000 365.9400 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 5 32.000000 2083.8400 65.1200
OCCT-97530HMGT-OT SESSION BY OT ASST 4 5.750000 374.4400 65.1200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 2 6.000000 487.9200 81.3200
PHY-97110-PT SESSION BY LICENSED PT 24 79.000000 6424.2800 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 3 4.000000 325.2800 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 2 4.000000 325.2800 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 155.000000 12604.6000 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 18.250000 1484.0900 81.3200
Subtotal (Total Children Is Unduplicated) 192 810.000000 55849.0200 68.9494
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Total 993.000000 69290.7500 69.7792
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Number of Children (Unduplicated) With at Least One Service 250
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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 0 0.000000 0.0000 0.0000
P 7 5.280000 429.8600 429.8600
D 48 49.220000 3597.9800 0.0000
S 1 0.250000 9.3000 0.0000
H 106 107.250000 8309.1700 0.0000
T 121 123.830000 7702.9100 7106.9900
648 707.170000 49241.5300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 931 993.000000 69290.7500 7536.8500