CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2025 ending 03/31/2025 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
Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.9200 7.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 15.1900 15.1900
EXIT-EXIT-COS Exit 12 12.000000 600.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 13.500000 1093.2300 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 809.8000 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 36.500000 2187.0800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 56.500000 4575.3700 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 323.9200 80.9800
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 107.2800 53.6400
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 265.2000 44.2000
Subtotal (Total Children Is Unduplicated) 80 155.500000 10797.0200 69.4342
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 40.6600 20.3300
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 15 17.250000 862.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 33 35.750000 1787.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 38 39.000000 1950.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 33 31.000000 1550.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 14 14.000000 700.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 1 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 7 7.000000 350.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 7 7.000000 350.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 122 647.500000 34965.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 18 31.750000 1714.5000 54.0000
EPIC-99601-Early Steps Professional Development Fee 325 1828.000000 27420.0000 15.0000
INTR-T1013-INTERPRETER 29 88.000000 4400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 81 509.000000 6108.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 42 195.000000 15687.5000 80.4487
OCCT-97530HM-OT SESSION BY OT ASST 2 2.500000 162.8000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 12 35.500000 2983.5600 84.0439
PHY-97110HM-PT SESSION BY PT ASST 4 11.750000 524.3200 44.6230
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 169.750000 13369.2000 78.7582
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 20.000000 1253.2600 62.6630
TRAV-TRAVS-Travel by mile 131 6657.000000 2961.8100 0.4449
Subtotal (Total Children Is Unduplicated) 488 10352.75000 119290.6100 11.5226
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Total 10508.250000 130087.6300 12.3796
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Number of Children (Unduplicated) With at Least One Service 512
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Center 02
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 0 0.000000 0.0000 0.0000
D 1 1.000000 54.0000 5.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3175 7759.250000 100991.5600 101003.4700
985 2748.000000 29042.0700 12.0000
Other 0 0.000000 0.0000 0.0000
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Total 4161 10508.250000 130087.6300 101020.4700