CMS/EIP Fiscal Report Center: 54
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
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 4 2.250000 83.7000 37.2000
Subtotal (Total Children Is Unduplicated) 4 2.250000 83.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 283.4300 80.9800
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
Subtotal (Total Children Is Unduplicated) 3 5.500000 445.3900 80.9800
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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 1 2.000000 148.8000 74.4000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 34.000000 1836.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 4.500000 243.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 30.000000 2439.6000 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 7 29.000000 2358.2800 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 3 3.000000 243.9600 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.000000 162.6400 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 3 20.000000 1966.5600 98.3280
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 130.2400 65.1200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 2 11.000000 894.5200 81.3200
PHY-97110-PT SESSION BY LICENSED PT 8 32.000000 2602.2400 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 57.800000 5177.1000 89.5692
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 11.750000 955.5100 81.3200
Subtotal (Total Children Is Unduplicated) 51 241.050000 19287.7100 80.0154
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Total 248.800000 19816.8000 79.6495
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Number of Children (Unduplicated) With at Least One Service 56
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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 16 15.000000 2248.2200 1589.1800
D 54 49.800000 3684.7000 0.0000
S 0 0.000000 0.0000 0.0000
H 24 24.000000 1903.0800 0.0000
T 11 11.000000 894.5200 81.3200
148 149.000000 11086.2800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 253 248.800000 19816.8000 1670.5000