CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:MED
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 1863 5379.500000 200033.7000 37.1844
Subtotal (Total Children Is Unduplicated) 1863 5379.500000 200033.7000 37.1844
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Screening, Eval, and Assessment,Class #02
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) 1 1.000000 7.9200 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 31.8100 31.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 23.1400 23.1400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 24 46.500000 3644.1000 78.3677
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 20 38.500000 2306.9200 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 323.9200 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 350 654.500000 53001.4100 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 13.000000 1052.7400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 72 117.500000 9596.1300 81.6692
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 283.4300 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 52 92.500000 7490.6500 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 283 527.500000 31577.8400 59.8632
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 299.6000 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 71 115.500000 9474.6600 82.0317
OCTH-97165-OT EVAL LOW COMPLEXITY 5 5.000000 290.5500 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 232.4400 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 8 8.000000 464.8800 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 12 12.000000 697.3200 58.1100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 14 79.000000 4590.6900 58.1100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 449 1742.000000 126249.9300 72.4741
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 724 5456.250000 294637.5000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 215 895.000000 48288.0000 53.9531
OCCT-97530-OT SESSION BY LICENSED OT 117 621.000000 50439.3700 81.2228
OCCT-97530GT-OT SESSION BY LICENSED OT 2 3.500000 284.6200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 16 58.000000 3776.9600 65.1200
PHY-97110-PT SESSION BY LICENSED PT 171 640.000000 52044.8000 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 2 4.000000 325.2800 81.3200
PHY-97110HM-PT SESSION BY PT ASST 20 116.500000 7586.4800 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 164 822.250000 66865.3700 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 15.000000 1219.8000 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 19.000000 1209.2400 63.6442
Subtotal (Total Children Is Unduplicated) 1107 8650.500000 526677.4200 60.8840
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Total 15772.000000 852961.0500 54.0807
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Number of Children (Unduplicated) With at Least One Service 2133
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Center 10
Flag Claims Units Chgs Paid
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R 294 298.500000 11225.8400 0.0000
U 0 0.000000 0.0000 0.0000
B 5955 6175.500000 288735.3000 0.0000
P 3 3.000000 162.0000 162.0000
D 1 1.000000 54.0000 0.0000
S 1 1.000000 65.1200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
10210 8911.250000 538517.6900 0.0000
Other 489 381.750000 14201.1000 0.0000
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Total 16953 15772.000000 852961.0500 162.0000