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
Payclass Filters:GR
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 1254 3128.000000 116370.9000 37.2030
Subtotal (Total Children Is Unduplicated) 1254 3128.000000 116370.9000 37.2030
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 6 6.000000 128.7600 21.4600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 96.9000 16.1500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 47.5200 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 190.8600 31.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.000000 138.8400 23.1400
EXIT-EXIT-COS Exit 15 15.250000 762.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.500000 416.2500 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 37 70.500000 5287.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 12.500000 937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 58.000000 3274.5000 56.4569
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 17.500000 1312.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 8 8.000000 398.4300 49.8038
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 3.000000 46.2900 15.4300
Subtotal (Total Children Is Unduplicated) 86 260.750000 15768.9000 60.4752
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 996.0000 996.0000
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
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 7 27.000000 1350.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 507 4905.000000 245250.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 204 1163.000000 58150.0000 50.0000
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 47 273.750000 19876.8900 72.6096
OCCT-97530HM-OT SESSION BY OT ASST 8 40.500000 2332.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 54 300.000000 21366.6000 71.2220
PHY-97110GT-PT SESSION BY LICENSED PT 1 4.500000 323.8200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 3 25.500000 1467.7800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 71 467.500000 33411.4400 71.4683
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 18.250000 1313.2700 71.9600
Subtotal (Total Children Is Unduplicated) 1772 27019.50000 694755.8500 25.7131
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Total 30408.250000 826895.6500 27.1931
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Number of Children (Unduplicated) With at Least One Service 2378
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Center 10
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 27728 27063.000000 696396.5800 696396.5800
D 8 7.500000 266.5200 0.0000
S 3 3.000000 36.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4183 3334.750000 130196.5500 105.0000
Other 0 0.000000 0.0000 0.0000
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Total 31922 30408.250000 826895.6500 696501.5800