CMS/EIP Fiscal Report Center: 57
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 623 574.750000 21371.4000 37.1838
TCM-T1017TL-TARGETED CASE MANAGEMENT 1607 7012.500000 261367.2000 37.2716
Subtotal (Total Children Is Unduplicated) 1630 7587.250000 282738.6000 37.2650
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 15.1900 15.1900
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 21.4600 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-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 46.2800 23.1400
EXIT-EXIT-COS Exit 2 7.000000 350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 16.000000 1200.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 19 32.500000 1803.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 8.500000 471.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 160 260.000000 19511.9600 75.0460
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 15 24.000000 1800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 162 259.000000 19425.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 34.000000 2550.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 79 125.500000 9412.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 21 31.000000 2327.9900 75.0965
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 365 604.000000 33569.8400 55.5792
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 56 87.500000 4856.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 58.000000 4311.0000 74.3276
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 25 25.000000 1291.9500 51.6780
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 25 25.000000 1285.2500 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 10 10.000000 514.1000 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 12 12.000000 616.9200 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 6 6.000000 308.4600 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 38 38.000000 1953.5800 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 555 1710.500000 110337.3300 64.5059
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 2757.7200 2757.7200
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 8.750000 437.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 201 205.000000 10250.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 18 19.000000 950.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 10 11.000000 550.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 15 17.000000 850.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 378 381.000000 19050.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 24 24.000000 1200.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 23 464.000000 11634.0000 25.0733
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1445 13965.75000 698112.5000 49.9875
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 46 167.000000 8558.0000 51.2455
EPIC-99601-Early Steps Professional Development Fee 985 9595.000000 143877.0000 14.9950
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 589 4722.000000 56664.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 104 733.000004 52803.5600 72.0376
OCCT-97530HM-OT SESSION BY OT ASST 64 255.000000 14716.8000 57.7129
OCCT-97530TL-OT SESSION BY LICENSED OT 4 7.500000 539.7000 71.9600
OCCT-97530TLHM-OT SESSION BY OT ASST 1 3.000000 172.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 30 207.250000 14870.5300 71.7517
PHY-97110GT-PT SESSION BY LICENSED PT 6 29.500000 2122.8200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 53 421.750000 24406.0900 57.8686
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 96 471.500000 34002.5600 72.1157
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 11.000000 810.2800 73.6618
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 75 358.000000 20612.9400 57.5780
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 3.500000 251.8600 71.9600
TRAV-TRAVS-Travel by mile 5 2516.000000 1119.6100 0.4450
Subtotal (Total Children Is Unduplicated) 1549 34599.50000 1121420.2700 32.4115
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Total 43897.250004 1514496.2000 34.5009
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Number of Children (Unduplicated) With at Least One Service 1912
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Center 57
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 11 8.008426 550.2400 550.2400
D 216 216.000000 6569.1000 0.0000
S 0 0.000000 0.0000 0.0000
H 3676 5495.500000 242048.0600 240777.8100
T 20724 23050.705609 521772.7800 521772.7800
15355 15119.035969 743258.4200 315.4800
Other 9 8.000000 297.6000 0.0000
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Total 39991 43897.250004 1514496.2000 763416.3100