CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2024 ending 03/31/2024 Date of Report:04/04/2025 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 3 1.500000 55.8000 37.2000
Subtotal (Total Children Is Unduplicated) 3 1.500000 55.8000 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 15.8400 15.8400
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 26.4300 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 115.6800 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.8100 13.8100
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 18 25.500000 1912.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 10.500000 975.0000 92.8571
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 23.000000 1725.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 17.500000 1500.0000 85.7143
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 39.000000 2164.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 60 162.500000 11050.9200 68.0057
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 5.000000 829.4400 165.8880
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 45 231.000000 11550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 23.250000 1162.5000 50.0000
EPIC-99601-Early Steps Professional Development Fee 1 1.000000 15.0000 15.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 153.264310 11204.9800 73.1089
OCCT-97530GT-OT SESSION BY LICENSED OT 16 43.500000 3130.2600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 2 8.000000 575.6800 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 26 141.250000 12348.8700 87.4256
PHY-97110GT-PT SESSION BY LICENSED PT 9 11.250000 1313.6700 116.7707
PHY-97110TL-PT SESSION BY LICENSED PT 3 11.000000 959.6000 87.2364
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 164.750000 12691.2500 77.0334
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 14.000000 1271.5600 90.8257
Subtotal (Total Children Is Unduplicated) 141 809.264310 57174.7700 70.6503
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Total 973.264310 68281.4900 70.1572
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Number of Children (Unduplicated) With at Least One Service 184
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Center 53
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 50 48.250000 7970.8700 4451.8300
D 461 488.000000 34189.6900 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 280 285.442340 16492.7409 15280.1000
149 151.571970 9628.1891 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 940 973.264310 68281.4900 19731.9300