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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1037 7555.750000 280962.3000 37.1852
Subtotal (Total Children Is Unduplicated) 1037 7555.750000 280962.3000 37.1852
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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 12 23.000000 1862.5400 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 29.500000 2278.0300 77.2214
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 20 38.500000 3037.0000 78.8831
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 473.9200 78.9867
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 13 27.000000 2126.6600 78.7652
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 30 58.500000 3496.4800 59.7689
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 44 90.500000 5268.0600 58.2106
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 10 19.500000 1579.1100 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 4 7.500000 607.3500 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 33.500000 2578.2800 76.9636
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 40 80.600000 6272.2400 77.8194
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 68.000000 5354.1500 78.7375
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 70 130.600000 10141.8400 77.6557
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 27.000000 2108.7200 78.1007
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 34 65.000000 5000.5800 76.9320
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 73 134.500000 7789.6200 57.9154
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 153 296.500000 16990.5700 57.3038
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 134.000000 10432.7200 77.8561
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 80.000000 6245.1800 78.0648
Subtotal (Total Children Is Unduplicated) 369 1365.200000 95159.6100 69.7038
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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 12 16.000000 1170.0800 73.1300
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 53 538.500000 41986.6800 77.9697
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) 794 11843.22000 703439.5300 59.3960
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Total 20764.170000 1079561.4400 51.9916
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Number of Children (Unduplicated) With at Least One Service 1058
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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 1637 1473.500000 74987.2500 46212.3000
P 11833 10650.750000 525737.1300 525233.0400
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
8233 8477.500000 468535.3600 0.0000
Other 110 96.700000 5545.5600 744.4500
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Total 21883 20764.170000 1079561.4400 572461.4700