CMS/EIP Fiscal Report Center: 02
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Payclass Filters:GR
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 58 58.000000 2900.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 203.0900 58.0257
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 21.500000 1636.4200 76.1126
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 15.500000 1183.4300 76.3503
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 39.000000 2239.6400 57.4267
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 64.500000 4978.0300 77.1788
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 122 217.000000 14000.5200 64.5185
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 183.7400 91.8700
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 70 96.500000 4825.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 93 103.000000 5150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 94 124.500000 6225.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 97 108.250000 5412.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 4 3.500000 87.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 27 31.500000 1575.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 19 12.500000 625.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 12.000000 600.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 46 55.750000 2787.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 154 2100.500000 110274.0000 52.4989
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 53 142.500000 7475.0000 52.4561
EPIC-99601-Early Steps Professional Development Fee 402 6034.000000 90539.0000 15.0048
INTR-T1013-INTERPRETER 42 212.500000 10625.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 179 1822.000000 21867.0000 12.0016
OCCT-97530-OT SESSION BY LICENSED OT 18 156.500000 12345.1000 78.8824
OCCT-97530GT-OT SESSION BY LICENSED OT 2 11.000000 810.2800 73.6618
PHY-97110-PT SESSION BY LICENSED PT 2 12.500000 1016.5000 81.3200
PHY-97110HM-PT SESSION BY PT ASST 1 1.500000 97.6800 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 55.500000 4348.5300 78.3519
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 243.9600 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 65.1200 65.1200
TRAV-TRAVS-Travel by mile 186 17270.00000 7683.4500 0.4449
Subtotal (Total Children Is Unduplicated) 568 28373.00000 294886.8600 10.3932
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Total 28590.000000 308887.3800 10.8040
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Number of Children (Unduplicated) With at Least One Service 583
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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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 11332 27723.000000 291719.1300 276310.5500
651 864.000000 17318.2500 0.0000
Other 3 3.000000 -150.0000 150.0000
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Total 11986 28590.000000 308887.3800 276460.5500