CMS/EIP Fiscal Report Center: 57
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 577 537.500000 19995.0000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1633 6608.000000 245817.6000 37.2000
Subtotal (Total Children Is Unduplicated) 1678 7145.500000 265812.6000 37.2000
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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-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 31.8100 31.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 23.1400 23.1400
EXIT-EXIT-COS Exit 5 12.500000 625.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 19.000000 1538.6200 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 18.500000 1498.1300 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 21 35.500000 2169.2800 61.1065
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 6.000000 359.5200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 92 154.500000 12511.4100 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 18 31.000000 2510.3800 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 120 200.500000 16236.4900 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 13 18.500000 1498.1300 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 71 109.500000 8867.3100 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 31.000000 2510.3800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 271 465.000000 27862.8000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 48 78.500000 4703.7200 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 20.500000 1660.0900 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.000000 404.9000 80.9800
OCTF-97168-OT RE-EVAL EST PLAN CARE 9 9.000000 522.9900 58.1100
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 174.3300 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 22 22.000000 1278.4200 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 232.4400 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 5 5.000000 290.5500 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 7.000000 406.7700 58.1100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 23 23.000000 1336.5300 58.1100
Subtotal (Total Children Is Unduplicated) 399 1294.500000 90128.1100 69.6239
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.000000 200.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 148 150.000000 7500.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 70 70.000000 3500.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 19.000000 950.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 275 276.000000 13800.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 143 143.000000 7150.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 26 564.000000 15216.0000 26.9787
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1365 13964.00000 754056.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 32 123.000000 6642.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 1032 10124.00000 151860.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 554 4081.000000 48972.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 45 262.750000 21271.1700 80.9559
OCCT-97530GO-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 31 112.500000 7326.0000 65.1200
OCCT-97530TLHM-OT SESSION BY OT ASST 1 4.000000 260.4800 65.1200
PHY-97110-PT SESSION BY LICENSED PT 22 54.500000 4431.9400 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 4 24.500000 1992.3400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 23 116.500000 7586.4800 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 132.500000 10721.9600 80.9205
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 11.000000 894.5200 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 18 44.000000 2865.2800 65.1200
TRAV-TRAVS-Travel by mile 9 3097.000000 1378.1200 0.4450
Subtotal (Total Children Is Unduplicated) 1437 33380.25000 1068786.9300 32.0185
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Total 41820.250000 1424727.6400 34.0679
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Number of Children (Unduplicated) With at Least One Service 1924
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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 1 3.750000 139.5000 0.0000
P 26 18.657438 1393.1500 1195.9300
D 188 188.000000 5522.6700 0.0000
S 0 0.000000 0.0000 0.0000
H 3225 4716.500000 203526.1600 203399.8100
T 20522 23456.790341 542893.4000 542893.4000
13320 13433.052221 671122.5600 138.6000
Other 6 3.500000 130.2000 0.0000
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Total 37288 41820.250000 1424727.6400 747627.7400