CMS/EIP Fiscal Report Center: 10
Services beginning 04/01/2025 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 767 2009.750000 74485.7000 37.0622
Subtotal (Total Children Is Unduplicated) 767 2009.750000 74485.7000 37.0622
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Screening, Eval, and Assessment,Class #02
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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.9200 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 31.8100 31.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 23.1400 23.1400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 32.500000 2631.8500 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.500000 202.4500 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 18 34.000000 2037.2800 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 48.500000 3927.5300 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 17.000000 1376.6600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 11.000000 890.7800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 47.500000 2846.2000 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 11.500000 931.2700 80.9800
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 232.4400 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 11 11.000000 639.2100 58.1100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 9 88.000000 5113.6800 58.1100
Subtotal (Total Children Is Unduplicated) 88 325.500000 21822.4800 67.0429
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 6.000000 30000.0000 5000.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 442 4642.500000 250695.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 96 533.000000 28782.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 89 557.250000 45315.5700 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 4 14.500000 1179.1400 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 1 6.000000 487.9200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 18 93.000000 6056.1600 65.1200
PHY-97110-PT SESSION BY LICENSED PT 101 511.000000 41538.5400 81.2887
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
PHY-97110HM-PT SESSION BY PT ASST 20 150.500000 9800.5600 65.1200
PHY-97110HMGT-PT SESSION BY PT ASST 2 2.000000 130.2400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 118 707.000000 57023.4400 80.6555
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 13.750000 1118.1500 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 68.000000 4428.1600 65.1200
Subtotal (Total Children Is Unduplicated) 641 7305.500000 476636.2000 65.2435
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Total 9640.750000 572944.3800 59.4294
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Number of Children (Unduplicated) With at Least One Service 902
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Center 10
Flag Claims Units Chgs Paid
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R 48 48.000000 1785.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 2564 2124.000000 86235.1000 0.0000
P 0 0.000000 0.0000 0.0000
D 1 1.000000 65.1200 0.0000
S 27 27.000000 1458.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8350 7415.750000 482470.5600 0.0000
Other 33 25.000000 930.0000 0.0000
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Total 11023 9640.750000 572944.3800 0.0000