CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 231 109.250000 4064.1000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3367 9195.000000 341905.2000 37.1838
Subtotal (Total Children Is Unduplicated) 3388 9304.250000 345969.3000 37.1840
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 15 16.000000 776.0000 48.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.9200 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 31.8100 31.8100
EXIT-EXIT-COS Exit 118 97.250000 4862.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 311.9600 77.9900
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 17 27.000000 1507.3400 55.8274
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.000000 395.1300 56.4471
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 77 132.500000 10053.7700 75.8775
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 52 91.000000 6303.8700 69.2733
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 48.000000 3653.8200 76.1213
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 31 51.000000 3914.7000 76.7588
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 33 58.500000 4492.1500 76.7889
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 28 52.500000 4036.1700 76.8794
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 278 474.500000 26705.4800 56.2813
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 124 215.500000 11999.1100 55.6803
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 245 432.500000 33125.0700 76.5898
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 173 321.500000 24614.8200 76.5624
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 219.0400 54.7600
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 12 60.000000 3138.2000 52.3033
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 7 25.000000 1379.0500 55.1620
Subtotal (Total Children Is Unduplicated) 888 2142.250000 142979.6600 66.7428
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 176 192.750000 9687.5000 50.2594
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 130 145.000000 7250.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 46 44.000000 1143.2500 25.9830
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 168 317.750000 15862.5000 49.9213
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 154 387.500000 13375.0000 34.5161
CONIP-CONIP-CONSULT, ITDS PHONE 7 6.500000 187.5000 28.8462
CONOF-CONOF-CONSULT, OT, FACE TO FACE 43 72.250000 3612.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 85 176.000000 8800.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 13 14.500000 362.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 27 29.250000 1462.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 89 146.000000 7300.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 10 13.750000 343.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 120 258.750000 9709.4600 37.5245
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 84 136.500000 6825.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 12 9.000000 250.0000 27.7778
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 717 4625.000000 231772.0000 50.1129
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 144 547.750000 27409.5000 50.0402
EPIC-99601-Early Steps Professional Development Fee 228 1591.000000 23865.0000 15.0000
INTR-T1013-INTERPRETER 178 385.250000 19165.0500 49.7470
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1642 13680.00000 164160.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 35 198.000000 14622.4800 73.8509
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 9 24.000000 1727.0400 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 11 55.000000 4107.5600 74.6829
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 11.000000 819.6400 74.5127
PHY-97110-PT SESSION BY LICENSED PT 77 521.000000 36623.4800 70.2946
PHY-97110GT-PT SESSION BY LICENSED PT 8 24.750000 1846.5300 74.6073
PHY-97110TL-PT SESSION BY LICENSED PT 12 54.000000 4145.5800 76.7700
PHY-97110TLGT-PT SESSION BY LICENSED PT 4 11.000000 829.0000 75.3636
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 137 777.250000 56038.9100 72.0990
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 14 63.500000 4597.5400 72.4022
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 9 26.750000 1943.6500 72.6598
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 3.000000 234.6000 78.2000
SPL-92508HA-GROUP SPL SESSION PER CHILD 2 5.000000 69.8000 13.9600
TRAV-TRAVS-Travel by mile 448 39712.00000 17704.7400 0.4458
Subtotal (Total Children Is Unduplicated) 2131 64272.75000 698211.5200 10.8633
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Total 75719.250000 1187160.4800 15.6785
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Number of Children (Unduplicated) With at Least One Service 3662
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Center 01
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 26315 62551.250000 640319.6500 640194.4700
D 561 1089.250000 21248.1800 0.0000
S 5 3.250000 171.5000 0.0000
H 8854 7294.750000 331530.4400 285065.6100
T 1 1.000000 71.9600 71.9600
6724 4748.750000 192665.5500 0.0000
Other 67 31.000000 1153.2000 0.0000
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Total 42527 75719.250000 1187160.4800 925332.0400