CMS/EIP Fiscal Report Center: 57
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
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 599 441.250000 16414.5000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1584 6134.500000 228203.4000 37.2000
Subtotal (Total Children Is Unduplicated) 1615 6575.750000 244617.9000 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-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 15.1900 15.1900
EXIT-EXIT-COS Exit 2 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 11.500000 931.2700 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 31.000000 2510.3800 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.000000 242.9400 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 8.000000 647.8400 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 29 51.000000 3055.9200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.000000 299.6000 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 118 202.000000 16357.9600 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.500000 526.3700 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 183 297.000000 24019.4700 80.8736
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 22.000000 1781.5600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 100 154.500000 12511.4100 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 13.500000 1093.2300 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 388 667.000000 39966.6400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 26 41.000000 2456.7200 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 17.000000 1376.6600 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 242.9400 80.9800
OCTF-97168-OT RE-EVAL EST PLAN CARE 8 8.000000 464.8800 58.1100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 290.5500 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 232.4400 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 174.3300 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 10.000000 581.1000 58.1100
Subtotal (Total Children Is Unduplicated) 484 1579.500000 110517.9200 69.9702
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 1.500000 75.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 81 82.000000 4100.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 30 30.000000 1500.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 146 146.000000 7300.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 84 84.000000 4200.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 26 474.000000 12798.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1246 8062.750000 435388.5000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 33 72.000000 3888.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 914 5802.000000 87030.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 376 2182.000000 26184.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 46 192.500000 15654.1000 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 35 121.500000 7912.0800 65.1200
PHY-97110-PT SESSION BY LICENSED PT 19 48.000000 3903.3600 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 3 3.000000 243.9600 81.3200
PHY-97110HM-PT SESSION BY PT ASST 23 93.500000 6088.7200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 146.250000 11893.0500 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 243.9600 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 23 52.500000 3418.8000 65.1200
TRAV-TRAVS-Travel by mile 9 2757.000000 1226.8200 0.4450
Subtotal (Total Children Is Unduplicated) 1315 20358.50000 633298.3500 31.1073
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Total 28513.750000 988434.1700 34.6652
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Number of Children (Unduplicated) With at Least One Service 1904
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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 0 0.000000 0.0000 0.0000
D 114 114.000000 3591.2800 0.0000
S 0 0.000000 0.0000 0.0000
H 2788 4291.750000 194165.7800 194066.0100
T 7044 8490.250000 185925.9800 185925.9800
13825 15566.250000 602835.3300 0.0000
Other 41 51.500000 1915.8000 0.0000
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Total 23812 28513.750000 988434.1700 379991.9900