CMS/EIP Fiscal Report Center: 54
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 943 6972.750000 259284.0000 37.1853
Subtotal (Total Children Is Unduplicated) 943 6972.750000 259284.0000 37.1853
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Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 3 4.000000 467.3200 116.8300
AACIS-92597TL-AAC INTIAL EVAL BY LICENSED SLP 3 3.000000 337.0200 112.3400
AACIS-92597TLGT-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 116.8300 116.8300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 595.3900 79.3853
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 13.000000 1052.7400 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 25.500000 1954.1100 76.6318
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 16 30.500000 2425.0400 79.5095
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 311.9600 77.9900
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 9 20.000000 1595.6800 79.7840
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 27 52.500000 3136.9600 59.7516
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 26 52.500000 3052.9800 58.1520
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 7 13.500000 1093.2300 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 3 5.500000 445.3900 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 28.000000 2156.8100 77.0289
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 31 61.500000 4791.9000 77.9171
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 48.000000 3782.3900 78.7998
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 59 111.500000 8688.4100 77.9230
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.000000 1148.9200 76.5947
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 23 44.500000 3427.2000 77.0157
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 62 114.000000 6596.6200 57.8651
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 111 215.500000 12320.4800 57.1716
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 57 110.000000 8549.0000 77.7182
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 63.000000 4913.3700 77.9900
Subtotal (Total Children Is Unduplicated) 283 1043.500000 72959.7500 69.9183
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 8 8.000000 377.9900 47.2488
AACFIT-92609TL-AAC FITTING, ADJUST, TRAINING VISIT 4 4.000000 191.7600 47.9400
AACFIT-92609TLGT-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 47.9400 47.9400
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 132.000000 3475.0000 26.3258
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 558 7437.750000 392645.5000 52.7909
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 282 974.750000 51400.5000 52.7320
OCCT-97530-OT SESSION BY LICENSED OT 13 55.010000 4267.0700 77.5690
OCCT-97530GO-OT SESSION BY LICENSED OT 3 5.000000 387.8800 77.5760
OCCT-97530GOGT-OT SESSION BY LICENSED OT 3 3.000000 243.9600 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 3 2.750000 207.2500 75.3636
OCCT-97530HM-OT SESSION BY OT ASST 3 9.000000 525.9200 58.4356
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 64 219.750000 15841.2900 72.0878
OCCT-97530TLGO-OT SESSION BY LICENSED OT 110 1096.000000 87053.2500 79.4281
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 39 91.010000 7229.4100 79.4353
OCCT-97530TLGT-OT SESSION BY LICENSED OT 11 14.000000 1026.1600 73.2971
OCCT-97530TLGTHM-OT SESSION BY OT ASST 7 13.000000 846.5600 65.1200
OCCT-97530TLHM-OT SESSION BY OT ASST 13 109.750000 7146.9200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 30 260.000000 20225.9200 77.7920
PHY-97110GPGT-PT SESSION BY LICENSED PT 1 2.000000 162.6400 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 5 5.000000 378.5200 75.7040
PHY-97110TL-PT SESSION BY LICENSED PT 52 537.500000 41914.7200 77.9809
PHY-97110TLGT-PT SESSION BY LICENSED PT 17 40.250000 3114.0100 77.3667
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 39 387.200000 30625.2200 79.0941
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 16 47.500000 3778.4600 79.5465
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 48 335.750000 26367.1900 78.5322
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 18 48.250000 3685.0100 76.3733
Subtotal (Total Children Is Unduplicated) 792 11840.22000 703223.6500 59.3928
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Total 19856.470000 1035467.4000 52.1476
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Number of Children (Unduplicated) With at Least One Service 964
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Center 54
Flag Claims Units Chgs Paid
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R 7 9.500000 441.6400 55.8000
U 0 0.000000 0.0000 0.0000
B 1564 1385.500000 70834.7300 43044.0000
P 11273 9981.750000 495234.0600 494729.9700
D 18 17.500000 1354.2400 215.8800
S 33 31.700000 2431.2400 0.0000
H 12 7.020000 529.0200 0.0000
T 0 0.000000 0.0000 0.0000
8165 8346.500000 460163.6300 0.0000
Other 94 77.000000 4478.8400 673.2000
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Total 21166 19856.470000 1035467.4000 538718.8500