CMS/EIP Fiscal Report Center: 06
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 835 461.250000 17177.1000 37.2403
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 16 9.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1908 6360.750000 236657.1000 37.2058
Subtotal (Total Children Is Unduplicated) 1925 6831.750000 253834.2000 37.1551
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 56.1000 56.1000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 42.9200 21.4600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 16.1500 16.1500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 15.8400 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 63.6200 31.8100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 15.1900 15.1900
AUDE-V5010-ASSESSMENT FOR HEARING AID 4 4.000000 118.4400 29.6100
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
EXIT-EXIT-COS Exit 121 93.750000 4643.7500 49.5333
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 108 169.500000 12487.5000 73.6726
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 124 213.500000 16012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 114 185.000000 13770.7500 74.4365
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 118 205.500000 15412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 42 68.500000 5100.0000 74.4526
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 56 102.000000 7620.7500 74.7132
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 95 156.500000 8631.7500 55.1550
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 132 240.500000 13386.7500 55.6622
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 533 1473.250000 99190.3400 67.3276
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EI Services,Class #03
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 1.000000 47.3500 47.3500
AUDE-V5160-DISPENSING FEE BINAURAL 2 2.000000 461.2400 230.6200
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 81 92.250000 4350.0000 47.1545
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 91 114.750000 5512.5000 48.0392
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 59 54.750000 1337.5000 24.4292
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 7 11.000000 550.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 6 7.500000 375.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 3.500000 87.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 6.500000 325.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 7 8.000000 400.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.500000 62.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 6.000000 300.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 0.500000 25.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 936 7377.750000 367309.1000 49.7861
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 224 1032.500000 51008.0000 49.4024
EPIC-99601-Early Steps Professional Development Fee 509 4062.000000 60375.0000 14.8634
INTR-T1013-INTERPRETER 42 342.250000 21595.0000 63.0972
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 496 3755.000000 44907.0000 11.9593
OCCT-97530-OT SESSION BY LICENSED OT 14 63.000000 3774.8900 59.9189
OCCT-97530GO-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530GOGT-OT SESSION BY LICENSED OT 2 3.000000 215.8800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 6 28.500000 1906.9400 66.9102
OCCT-97530HM-OT SESSION BY OT ASST 2 8.500000 259.2000 30.4941
OCCT-97530HMGT-OT SESSION BY OT ASST 4 20.750000 1217.0900 58.6549
PHY-97110-PT SESSION BY LICENSED PT 22 223.500000 14097.5200 63.0762
PHY-97110GT-PT SESSION BY LICENSED PT 5 29.500000 1672.8700 56.7075
PHY-97110HM-PT SESSION BY PT ASST 13 87.250000 4905.9300 56.2284
PHY-97110HMGT-PT SESSION BY PT ASST 8 42.500000 2457.1000 57.8141
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 459.2200 459.2200
SENS-V5264-EARMOLD 8 14.000000 271.9500 19.4250
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 64 347.250000 23496.7100 67.6651
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 31 151.250000 10608.9000 70.1415
Subtotal (Total Children Is Unduplicated) 1191 17904.75000 624590.8100 34.8841
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Total 26209.750000 977615.3500 37.2997
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Number of Children (Unduplicated) With at Least One Service 2031
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Center 06
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 12676 12796.000000 360718.6300 360718.6300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
15867 13315.000000 613223.2200 0.0000
Other 192 98.750000 3673.5000 0.0000
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Total 28735 26209.750000 977615.3500 360718.6300