CMS/EIP Fiscal Report Center: 10
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 3167 8097.000000 301292.1000 37.2103
Subtotal (Total Children Is Unduplicated) 3167 8097.000000 301292.1000 37.2103
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 22 23.000000 493.5800 21.4600
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 26.0400 26.0400
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 22 23.000000 371.4500 16.1500
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.2300 23.2300
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 23 24.000000 190.0800 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 22 24.000000 731.6300 30.4846
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 22 23.000000 563.1300 24.4839
AUDE-V5010-ASSESSMENT FOR HEARING AID 4 5.000000 181.2800 36.2560
AUDE-V5090-DISPENSING FEE PER HEARING AID 4 5.000000 579.0500 115.8100
EXIT-EXIT-COS Exit 15 15.250000 762.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 48.500000 3637.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 17 31.500000 1748.2500 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 535 1008.000000 75938.1200 75.3354
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 38 73.000000 5475.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 90 158.000000 11933.7200 75.5299
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 11.500000 862.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 109 186.000000 14026.3700 75.4106
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 399 736.000000 40969.5500 55.6651
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 13 24.500000 1359.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 127 225.000000 17090.6500 75.9584
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.500000 337.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 16 16.000000 822.5600 51.4100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 17 22.000000 880.6700 40.0305
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 13.3500 13.3500
PSTH-97161-PT EVAL LOW COMPLEXITY 20 20.000000 1028.2000 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 51 52.000000 2619.9700 50.3840
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 10.000000 462.6900 46.2690
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 7 36.000000 1583.4700 43.9853
Subtotal (Total Children Is Unduplicated) 789 2822.250000 185736.7000 65.8116
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 2592.0000 1296.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 43 37.000000 1850.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 220 181.250000 9062.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 17 10.250000 256.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 69 83.250000 4162.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 282 511.000000 25550.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 20 30.000000 1500.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 26 43.500000 2200.0000 50.5747
CONOP-CONOP-CONSULT, OT, PHONE 2 6.000000 150.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 18.000000 900.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 69 87.250000 4362.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 24 40.750000 2037.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 230 406.750000 20337.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 8 28.500000 1425.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1269 12299.75000 615996.0000 50.0820
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 502 3234.500000 164287.0000 50.7921
EPIC-99601-Early Steps Professional Development Fee 567 5492.000000 82380.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1112 12845.00000 154131.0000 11.9993
OCCT-97530-OT SESSION BY LICENSED OT 393 2455.000000 173853.3300 70.8160
OCCT-97530GO-OT SESSION BY LICENSED OT 3 4.500000 337.8600 75.0800
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 3.500000 251.8600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 6 12.500000 899.5000 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 75 453.750000 25507.6300 56.2152
PHY-97110-PT SESSION BY LICENSED PT 471 2741.500000 193882.8800 70.7215
PHY-97110GT-PT SESSION BY LICENSED PT 6 12.000000 832.2200 69.3517
PHY-97110HM-PT SESSION BY PT ASST 30 185.500000 10709.9500 57.7356
SENS-V5050-IN EAR MONAURAL HEARING AID 4 4.000000 918.4400 229.6100
SENS-V5264-EARMOLD 5 6.000000 108.7800 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 586 3884.500000 274532.1500 70.6737
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 25 113.500000 8326.5800 73.3619
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 19.500000 905.4000 46.4308
Subtotal (Total Children Is Unduplicated) 2274 45255.00000 1784308.8300 39.4279
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Total 56174.250000 2271337.6300 40.4338
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Number of Children (Unduplicated) With at Least One Service 3602
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Center 10
Flag Claims Units Chgs Paid
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R 215 174.500000 6491.4000 0.0000
U 0 0.000000 0.0000 0.0000
B 6545 5943.250000 265302.0300 0.0000
P 32890 30411.750000 921233.7500 916597.9500
D 27 25.750000 749.9400 0.0000
S 12 7.500000 338.2200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
23962 19587.500000 1076329.4900 105.0000
Other 40 24.000000 892.8000 0.0000
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Total 63691 56174.250000 2271337.6300 916702.9500