CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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 658 439.500000 16340.1000 37.1788
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 96 74.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1649 5203.250000 193328.4000 37.1553
Subtotal (Total Children Is Unduplicated) 1684 5717.250000 209668.5000 36.6730
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Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 116.8300 116.8300
AACIS-92597TLGT-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 116.8300 116.8300
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 7 8.000000 388.0000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 32.3000 16.1500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 31.6800 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 127.2400 31.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 23.1400 23.1400
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 12.000000 971.7600 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.000000 809.8000 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 9 18.000000 1457.6400 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 12.000000 971.7600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 12 24.000000 1438.0800 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 14 28.000000 1677.7600 59.9200
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 73.000000 5887.6200 80.6523
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 30 58.000000 4696.8400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 52 97.000000 7697.7100 79.3578
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 92 175.500000 14654.6400 83.5022
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 40.500000 3279.6900 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 49 94.500000 7652.6100 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 105 201.000000 12043.9200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 168 331.000000 19951.0400 60.2750
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 104.000000 8386.0400 80.6350
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 63.500000 5142.2300 80.9800
SCREEN-T1023-SCREENING 1 1.000000 53.9800 53.9800
Subtotal (Total Children Is Unduplicated) 372 1366.500000 97786.1100 71.5595
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 3 3.000000 143.8200 47.9400
AACFIT-92609TL-AAC FITTING, ADJUST, TRAINING VISIT 3 3.000000 143.8200 47.9400
ASST-ASST-ASSISTIVE TECHNOLOGY 29 50.000000 4748.1400 94.9628
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 77 72.250000 3589.5000 49.6817
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 192 190.500000 9537.5000 50.0656
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 44 45.000000 2237.5000 49.7222
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 183 87.000000 4387.5000 50.4310
CONOF-CONOF-CONSULT, OT, FACE TO FACE 44 39.750000 2043.8200 51.4169
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 277 128.500000 6431.3200 50.0492
CONPF-CONPF-CONSULT, PT, FACE TO FACE 39 38.000000 1900.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 114 38.750000 1950.0000 50.3226
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 65 71.250000 3562.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 190 79.750000 3990.6600 50.0396
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 563 1655.000000 268.9600 0.1625
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 41.000000 1134.0000 27.6585
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 5 7.000000 350.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 609 2867.500000 154920.0000 54.0262
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 247 546.000000 29484.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 754 3236.000000 48774.9600 15.0726
INTR-T1013-INTERPRETER 2 5.500000 217.1600 39.4836
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 445 1870.000000 22452.0000 12.0064
OCCT-97530-OT SESSION BY LICENSED OT 42 361.680000 15306.9400 42.3218
OCCT-97530GO-OT SESSION BY LICENSED OT 29 100.000000 8053.9000 80.5390
OCCT-97530GOGT-OT SESSION BY LICENSED OT 11 32.250000 2622.5700 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 7 11.500000 935.1800 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 10 42.000000 2712.4800 64.5829
OCCT-97530HMGT-OT SESSION BY OT ASST 2 4.000000 260.4800 65.1200
OCCT-97530TL-OT SESSION BY LICENSED OT 3 6.750000 569.2400 84.3319
OCCT-97530TLGO-OT SESSION BY LICENSED OT 79 352.250000 28616.8100 81.2401
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 13 17.750000 1443.4300 81.3200
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530TLGTHM-OT SESSION BY OT ASST 6 8.000000 520.9600 65.1200
OCCT-97530TLHM-OT SESSION BY OT ASST 16 61.000000 3972.3200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 60 239.500000 19489.7400 81.3768
PHY-97110GT-PT SESSION BY LICENSED PT 9 11.000000 885.1600 80.4691
PHY-97110TL-PT SESSION BY LICENSED PT 39 182.750000 14861.2300 81.3200
PHY-97110TLGT-PT SESSION BY LICENSED PT 8 10.000000 813.2000 81.3200
SENS-V5264-EARMOLD 2 4.000000 72.5200 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 87 448.340000 37103.9300 82.7585
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 28 50.750000 4306.0000 84.8473
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 33 105.500000 8579.2600 81.3200
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 8 12.750000 1036.8300 81.3200
TRAV-TRAVS-Travel by mile 674 37530.00000 16695.0500 0.4448
Subtotal (Total Children Is Unduplicated) 1157 50667.52000 471205.7100 9.3000
CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 Page: 2
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
-----------------------------------------------------------------------------------------------------------------------
Total 57751.270000 778660.3200 13.4830
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Number of Children (Unduplicated) With at Least One Service 1799
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Center 54
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 170 169.750000 8056.6200 74.4200
P 4614 4325.510000 215251.9400 212115.7100
D 513 607.700000 27804.4500 431.7600
S 51 53.810000 1666.9400 0.0000
H 23 24.000000 1934.8000 0.0000
T 7516 42227.110000 155464.4800 155464.4800
12064 10215.890000 360664.7000 0.0000
Other 136 127.500000 7816.3900 2157.5600
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Total 25087 57751.270000 778660.3200 370243.9300