CMS/EIP Fiscal Report Center: 54
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
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1002 975.500000 36279.3000 37.1905
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 159 131.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 863 4100.500000 152389.6000 37.1637
Subtotal (Total Children Is Unduplicated) 1426 5207.750000 188668.9000 36.2285
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Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 116.8300 116.8300
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 32 34.000000 1649.0000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 48.4500 16.1500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 4.000000 31.6800 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 4.000000 127.2400 31.8100
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 11.000000 854.9000 77.7182
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 13.000000 1028.8200 79.1400
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 10 19.500000 1534.2600 78.6800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 461.9600 76.9933
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 599.2000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 24.500000 1423.8400 58.1159
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.500000 646.4700 76.0553
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 13.000000 992.9400 76.3800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 17.500000 1402.2000 80.1257
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 41.500000 3193.2300 76.9453
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 16.000000 1247.8400 77.9900
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 16 30.500000 2329.3600 76.3725
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 47.000000 2674.8000 56.9106
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 44 91.000000 5187.5200 57.0057
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 28.000000 2147.8400 76.7086
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 23.500000 1780.3100 75.7579
Subtotal (Total Children Is Unduplicated) 166 450.000000 29750.1600 66.1115
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 3 3.000000 132.7600 44.2533
ASST-ASST-ASSISTIVE TECHNOLOGY 73 162.000000 18106.7400 111.7700
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 231.6200 231.6200
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 192 228.750000 11487.5000 50.2186
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 472 665.250000 33300.0000 50.0564
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 131 186.000000 9300.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 325 224.500000 11250.0000 50.1114
CONIP-CONIP-CONSULT, ITDS PHONE 7 7.000000 175.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 140 173.750000 8743.8200 50.3241
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 519 370.000000 18450.0000 49.8649
CONOP-CONOP-CONSULT, OT, PHONE 1 2.000000 75.0000 37.5000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 83 117.500000 5840.0000 49.7021
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 220 113.000000 5650.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 136 211.750000 10587.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 379 229.750000 11490.6600 50.0138
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 762 5355.000000 372.9600 0.0696
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 6.000000 300.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 181 1646.750000 86874.5000 52.7551
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 95 347.750000 18355.5000 52.7836
EPIC-99601-Early Steps Professional Development Fee 952 10920.00000 163984.9600 15.0169
INTR-T1013-INTERPRETER 3 6.500000 205.5800 31.6277
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 606 6099.000000 73200.0000 12.0020
OCCT-97530-OT SESSION BY LICENSED OT 36 295.000000 23034.6800 78.0837
OCCT-97530GO-OT SESSION BY LICENSED OT 17 91.000000 7312.6600 80.3589
OCCT-97530GOGT-OT SESSION BY LICENSED OT 10 40.250000 3263.7700 81.0875
OCCT-97530GT-OT SESSION BY LICENSED OT 8 21.750000 1596.9900 73.4248
OCCT-97530HM-OT SESSION BY OT ASST 6 72.000000 4636.0000 64.3889
OCCT-97530HMGT-OT SESSION BY OT ASST 1 7.000000 448.3200 64.0457
OCCT-97530TL-OT SESSION BY LICENSED OT 2 5.000000 359.8000 71.9600
OCCT-97530TLGO-OT SESSION BY LICENSED OT 2 3.000000 234.6000 78.2000
PHY-97110-PT SESSION BY LICENSED PT 41 374.880000 29177.0800 77.8305
PHY-97110GT-PT SESSION BY LICENSED PT 6 9.880000 749.5200 75.8623
PHY-97110TL-PT SESSION BY LICENSED PT 2 4.000000 325.2800 81.3200
SENS-V5261-BEHIND EAR DIGITAL BINAURAL HEARING AID 1 1.000000 980.7400 980.7400
SENS-V5264-EARMOLD 2 8.000000 145.0400 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 56 415.000000 32195.5000 77.5795
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 18 43.000000 3330.6200 77.4563
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 3.500000 284.6200 81.3200
TRAV-TRAVS-Travel by mile 818 139860.0000 62218.7200 0.4449
Subtotal (Total Children Is Unduplicated) 1273 168331.5100 658433.0400 3.9115
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Total 173989.260000 876852.1000 5.0397
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Number of Children (Unduplicated) With at Least One Service 1699
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Center 54
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 532 392.260000 18332.7900 37.5000
S 62 68.000000 571.6300 0.0000
H 0 0.000000 0.0000 0.0000
T 21079 138030.000000 331744.8600 331510.8900
27425 35470.250000 525010.9900 0.0000
Other 39 28.750000 1191.8300 0.0000
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Total 49137 173989.260000 876852.1000 331548.3900