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:TPIN
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 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-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
Subtotal (Total Children Is Unduplicated) 6 13.000000 979.0300 75.3100
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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 40 179.000000 9666.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 18 30.500000 1647.0000 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 12 39.000000 3171.4800 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 162.6400 81.3200
SENS-V5261-BEHIND EAR DIGITAL BINAURAL HEARING AID 1 1.000000 980.7400 980.7400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 128.550000 10930.8200 85.0317
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 13.750000 1118.1500 81.3200
Subtotal (Total Children Is Unduplicated) 95 493.800000 36069.3700 73.0445
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Total 509.050000 37132.1000 72.9439
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Number of Children (Unduplicated) With at Least One Service 100
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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 157 156.090000 10007.6700 9194.4700
269 264.160000 19288.4300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 520 509.050000 37132.1000 10783.6500