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
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 459 1450.250000 53893.5000 37.1615
Subtotal (Total Children Is Unduplicated) 459 1450.250000 53893.5000 37.1615
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Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 2 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 2 4.000000 323.9200 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 11.000000 890.7800 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 11.000000 809.8000 73.6182
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 9.500000 769.3100 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.000000 80.9800 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 15 29.500000 1767.6400 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 13.500000 808.9200 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 485.8800 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 323.9200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 485.8800 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 15.000000 1214.7000 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1133.7200 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 27.500000 1647.8000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 13 26.000000 1557.9200 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 20.000000 1619.6000 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 16.000000 1295.6800 80.9800
Subtotal (Total Children Is Unduplicated) 62 225.000000 16214.7800 72.0657
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 47.9400 47.9400
AACFIT-92609TL-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 47.9400 47.9400
AACFIT-92609TLGT-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 47.9400 47.9400
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 10.000000 270.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 285 1672.750000 90328.5000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 80 153.250000 8275.5000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 8.000000 650.5600 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 49 270.000000 21956.4000 81.3200
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 8 37.000000 3008.8400 81.3200
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530TLGTHM-OT SESSION BY OT ASST 3 4.000000 260.4800 65.1200
OCCT-97530TLHM-OT SESSION BY OT ASST 7 27.750000 1807.0800 65.1200
PHY-97110-PT SESSION BY LICENSED PT 12 39.000000 3171.4800 81.3200
PHY-97110GPGT-PT SESSION BY LICENSED PT 1 2.000000 162.6400 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 21 86.500000 7034.1800 81.3200
PHY-97110TLGT-PT SESSION BY LICENSED PT 5 7.500000 609.9000 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 122.200000 9936.5400 81.3137
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 7 8.000000 650.5600 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 24 66.750000 5428.1100 81.3200
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 5 6.000000 487.9200 81.3200
Subtotal (Total Children Is Unduplicated) 405 2526.700000 154426.4700 61.1178
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Total 4201.950000 224534.7500 53.4358
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Number of Children (Unduplicated) With at Least One Service 503
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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 1500 1351.750000 68422.8900 45145.5700
P 1060 955.000000 48381.1200 48380.9200
D 1 0.500000 18.6000 0.0000
S 9 7.200000 541.2200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1821 1864.000000 106060.0000 0.0000
Other 25 14.000000 669.2800 135.3200
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Total 4423 4201.950000 224534.7500 93717.6100