CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2025 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
Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 3.000000 347.4300 115.8100
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 6.000000 485.8800 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 119.8400 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 329.5600 59.9200
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 283.4300 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 12.500000 1012.2500 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 18.000000 1078.5600 59.9200
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 8 55.000000 3196.0500 58.1100
Subtotal (Total Children Is Unduplicated) 26 115.500000 7594.1900 65.7506
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 2 0.750000 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 25 121.000000 6264.0000 51.7686
OCCT-97530-OT SESSION BY LICENSED OT 65 288.750000 23481.1500 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 6 28.500000 2317.6200 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 3.000000 243.9600 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 7 38.000000 2474.5600 65.1200
PHY-97110-PT SESSION BY LICENSED PT 82 512.250000 41656.1700 81.3200
PHY-97110GP-PT SESSION BY LICENSED PT 1 2.250000 182.9700 81.3200
PHY-97110HM-PT SESSION BY PT ASST 1 11.000000 716.3200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 110 608.500000 48559.9900 79.8028
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 243.9600 81.3200
Subtotal (Total Children Is Unduplicated) 207 1618.000000 126194.7000 77.9943
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Total 1733.500000 133788.8900 77.1785
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Number of Children (Unduplicated) With at Least One Service 219
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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 1336 1310.750000 100609.3200 100609.3200
D 13 13.000000 661.8400 0.0000
S 1 2.000000 161.9600 0.0000
H 20 20.750000 1644.5900 1644.5900
T 206 208.500000 16751.2500 16751.2500
184 176.500000 13797.9700 0.0000
Other 1 2.000000 161.9600 0.0000
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Total 1761 1733.500000 133788.8900 119005.1600