CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Payclass Filters:TPIN
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 8 9.250000 344.1000 37.2000
Subtotal (Total Children Is Unduplicated) 8 9.250000 344.1000 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 3.000000 347.4300 115.8100
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 16.500000 1276.3700 77.3558
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 11.500000 931.2700 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 11 25.500000 1996.2200 78.2831
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.500000 688.3300 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.500000 271.4700 77.5629
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 10 19.000000 1103.1200 58.0589
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 19 37.500000 2185.1200 58.2699
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 117.500000 8848.2500 75.3043
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 15 27.500000 2176.1200 79.1316
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 68.000000 5159.8000 75.8794
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 57 108.500000 8379.6900 77.2322
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 30.000000 2243.8900 74.7963
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 23.000000 1769.8500 76.9500
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 88 163.000000 9288.6900 56.9858
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 95 180.000000 10381.8200 57.6768
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 3 5.000000 250.0000 50.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 8 9.000000 569.4100 63.2678
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 109.5200 54.7600
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 109.5200 54.7600
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 116.2200 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 174.3300 58.1100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 12.000000 700.4300 58.3692
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 29 608.000000 32968.3100 54.2242
Subtotal (Total Children Is Unduplicated) 292 1494.500000 92622.3300 61.9755
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 4.000000 3498.0000 874.5000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 2 1.250000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 54.0000 54.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 108 590.000000 30930.0000 52.4237
EPIC-99601-Early Steps Professional Development Fee 2 13.000000 39.0000 3.0000
OCCT-97530-OT SESSION BY LICENSED OT 129 1410.500000 111875.4700 79.3162
OCCT-97530GO-OT SESSION BY LICENSED OT 8 42.500000 3437.3800 80.8795
OCCT-97530GOGT-OT SESSION BY LICENSED OT 3 5.000000 387.8800 77.5760
OCCT-97530GT-OT SESSION BY LICENSED OT 5 7.000000 513.0800 73.2971
OCCT-97530HM-OT SESSION BY OT ASST 22 217.000000 13664.8000 62.9714
PHY-97110-PT SESSION BY LICENSED PT 177 2835.750000 222412.1500 78.4315
PHY-97110GP-PT SESSION BY LICENSED PT 1 2.250000 182.9700 81.3200
PHY-97110HM-PT SESSION BY PT ASST 1 19.000000 1237.2800 65.1200
PHY-97110HMGT-PT SESSION BY PT ASST 1 1.000000 65.1200 65.1200
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 459.2200 229.6100
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 304 4225.750000 328080.4000 77.6384
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 9.000000 722.5200 80.2800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 17.000000 979.2000 57.6000
TRAV-TRAVS-Travel by mile 3 91.000000 40.4800 0.4448
Subtotal (Total Children Is Unduplicated) 551 9496.000000 718615.2100 75.6756
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Total 10999.750000 811581.6400 73.7818
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Number of Children (Unduplicated) With at Least One Service 728
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Center 09
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 9962 9965.500000 732161.7100 722818.1700
D 57 57.000000 2904.2400 0.0000
S 1 2.000000 161.9600 0.0000
H 176 273.750000 18713.5800 18602.5800
T 230 221.250000 17733.4400 17733.4400
467 463.250000 38783.2900 16600.3900
Other 9 17.000000 1123.4200 0.0000
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Total 10902 10999.750000 811581.6400 775754.5800