CMS/EIP Fiscal Report Center: 07
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:GR
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 1819 2497.250000 92685.8000 37.1151
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 115 217.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 788 1699.500000 63102.7500 37.1302
Subtotal (Total Children Is Unduplicated) 1945 4414.500000 155788.5500 35.2902
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 15.8400 15.8400
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.6800 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 9.000000 78.4000 8.7111
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 6.000000 176.4100 29.4017
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 45.0800 45.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 42.8100 14.2700
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.000000 67.3200 22.4400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.101700 77.2600 70.1280
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 555.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 44.365500 2995.8075 67.5256
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 11 21.152800 1586.4600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 19.258400 1428.0000 74.1495
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 39.443900 2949.2800 74.7715
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 6.424900 478.7200 74.5101
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 81 162.000000 8991.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 44 88.000000 4884.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 43.856900 3072.7100 70.0622
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 16.254100 1152.3700 70.8972
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 103.9500 34.6500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 6 6.000000 308.4600 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 3.000000 154.2300 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 11 11.000000 565.5100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 389.4400 43.2711
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 4 27.000000 1163.0700 43.0767
Subtotal (Total Children Is Unduplicated) 204 561.858200 33116.6775 58.9413
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 3483.3300 1741.6650
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 79 75.750000 3787.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 208 242.500000 12125.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 22 18.000000 450.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 250 442.000000 22100.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 267 529.500000 26475.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 2.750000 68.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 131 185.000000 9250.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 125 181.750000 9087.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 49 79.750000 3987.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 55 90.500000 4525.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 159 243.750000 12187.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 134 201.250000 10062.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 9 11.000000 275.0000 25.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 82 155.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 584 4936.000000 246476.2400 49.9344
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 113 308.750000 15445.5000 50.0259
EPIC-99601-Early Steps Professional Development Fee 735 6602.000000 99030.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1184 11030.00000 132348.4400 11.9990
OCCT-97530-OT SESSION BY LICENSED OT 34 201.250000 12942.4800 64.3105
OCCT-97530GO-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 3 19.000000 1367.2400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 37 239.250000 16816.7300 70.2894
PHY-97110GT-PT SESSION BY LICENSED PT 3 11.750000 696.7300 59.2962
PHY-97110HM-PT SESSION BY PT ASST 1 8.000000 460.4800 57.5600
SENS-V5264-EARMOLD 1 4.000000 72.5200 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 56 357.500000 21523.6700 60.2061
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 52.000000 2419.2000 46.5231
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 4 57.750000 3326.4000 57.6000
TRAV-TRAVS-Travel by mile 66 3612.000000 1606.9200 0.4449
Subtotal (Total Children Is Unduplicated) 1711 29906.50000 672734.9700 22.4946
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Total 34882.858200 861640.1975 24.7010
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Number of Children (Unduplicated) With at Least One Service 2396
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Center 07
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 26677 30046.750000 688439.9000 688439.9000
D 86 59.750000 2257.4600 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
8514 4790.608200 171596.5875 0.0000
Other 22 -14.250000 -653.7500 -681.6500
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Total 35299 34882.858200 861640.1975 687758.2500