CMS/EIP Fiscal Report Center: 10
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 2136 11225.75000 417441.8000 37.1861
Subtotal (Total Children Is Unduplicated) 2136 11225.75000 417441.8000 37.1861
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 7 7.000000 150.2200 21.4600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.000000 113.0500 16.1500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 63.3600 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 222.6700 31.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 7 7.000000 161.9800 23.1400
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.3200 45.3200
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 62 119.000000 9374.6200 78.7783
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 14.000000 1109.8000 79.2714
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 14.000000 1109.8000 79.2714
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 51 97.000000 5776.8800 59.5555
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 485.8800 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 327 601.000000 46178.3100 76.8358
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 26 51.000000 3908.7200 76.6416
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 68 112.000000 8707.9700 77.7497
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 574.4600 76.5947
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 82 140.000000 10755.7700 76.8269
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 248 449.500000 25621.3000 56.9996
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 9 17.000000 958.9700 56.4100
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 65 115.000000 8858.2200 77.0280
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 35.9800 35.9800
OCTH-97165-OT EVAL LOW COMPLEXITY 20 21.000000 1200.2100 57.1529
OCTH-97166-OT EVAL MODERATE COMPLEXITY 20 20.000000 1135.4000 56.7700
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 20 22.000000 1211.4200 55.0645
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 44 49.000000 2760.2900 56.3324
SPCH-92521GT-EVAL OF SPEECH FLUENCY 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 335.2600 55.8767
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 23 249.000000 14429.6400 57.9504
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 547 2159.000000 146031.7700 67.6386
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 6.000000 30000.0000 5000.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 956 23980.50000 1266948.0000 52.8324
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 415 5189.000000 274498.0000 52.9000
OCCT-97530-OT SESSION BY LICENSED OT 232 3298.000000 259242.4700 78.6060
OCCT-97530GO-OT SESSION BY LICENSED OT 10 31.000000 2492.8400 80.4142
OCCT-97530GT-OT SESSION BY LICENSED OT 6 21.500000 1678.1800 78.0549
OCCT-97530HM-OT SESSION BY OT ASST 57 569.500000 35401.1100 62.1617
PHY-97110-PT SESSION BY LICENSED PT 276 3652.000000 287099.3700 78.6143
PHY-97110GT-PT SESSION BY LICENSED PT 6 4.000000 311.2400 77.8100
PHY-97110HM-PT SESSION BY PT ASST 35 493.500000 31477.5600 63.7843
PHY-97110HMGT-PT SESSION BY PT ASST 2 2.000000 130.2400 65.1200
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 229.6100 229.6100
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 302 4271.250000 334196.2700 78.2432
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 22 87.000000 6852.5400 78.7648
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 96.000000 6202.6800 64.6113
Subtotal (Total Children Is Unduplicated) 1502 41704.25000 2536803.2400 60.8284
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Total 55089.000000 3100276.8100 56.2776
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Number of Children (Unduplicated) With at Least One Service 2233
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Center 10
Flag Claims Units Chgs Paid
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R 249 219.750000 8307.7000 0.0000
U 0 0.000000 0.0000 0.0000
B 14922 12480.250000 521349.6400 0.0000
P 36 55.250000 3526.3600 428.0000
D 4 3.000000 189.4100 0.0000
S 36 33.500000 1847.5300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
49353 42272.250000 2564126.1700 0.0000
Other 33 25.000000 930.0000 0.0000
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Total 64633 55089.000000 3100276.8100 428.0000