CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2023 ending 06/30/2024 Date of Report:04/12/2025 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 19 29.000000 1078.8000 37.2000
Subtotal (Total Children Is Unduplicated) 19 29.000000 1078.8000 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 3 3.000000 47.5200 15.8400
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 29.3600 14.6800
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 8.8100 8.8100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 10.000000 88.1000 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 11 12.000000 347.0400 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 55.2400 13.8100
AUDE-92652-AEP THRSHLD EST MLT FREQ I&R 2 2.000000 150.2600 75.1300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 10.500000 582.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 44.000000 3448.5000 78.3750
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 72 121.000000 9225.0000 76.2397
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 28.470000 2472.9300 86.8609
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 73 124.500000 9525.0000 76.5060
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 28.000000 2100.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 54 92.500000 7312.5000 79.0541
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 33.000000 1831.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 117 206.000000 11422.0000 55.4466
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 0.580000 30.0000 51.7241
Subtotal (Total Children Is Unduplicated) 254 754.050000 51015.4200 67.6552
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 6.000000 2789.4400 464.9067
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 231.6200 231.6200
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 1 1.250000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 2.000000 100.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 98 775.000000 38750.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 58 124.250000 6199.7000 49.8970
EPIC-99601-Early Steps Professional Development Fee 8 13.000000 195.0000 15.0000
OCCT-97530-OT SESSION BY LICENSED OT 58 611.956910 45533.1000 74.4057
OCCT-97530GT-OT SESSION BY LICENSED OT 27 105.000000 8612.2800 82.0217
OCCT-97530TL-OT SESSION BY LICENSED OT 3 9.000000 647.6400 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 3.500000 251.8600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 47 601.350000 63487.7000 105.5753
PHY-97110GT-PT SESSION BY LICENSED PT 18 21.250000 2033.2700 95.6833
PHY-97110TL-PT SESSION BY LICENSED PT 3 16.000000 1655.4800 103.4675
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 359.4200 359.4200
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 76 698.880000 52546.6300 75.1869
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 37 93.770000 8086.6600 86.2393
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 3 5.000000 359.8000 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 273 3094.206910 232047.8200 74.9943
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Total 3877.256910 284142.0400 73.2843
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Number of Children (Unduplicated) With at Least One Service 421
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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 412 365.400000 55314.0300 34140.0500
D 1804 1890.150000 131597.5500 31.5700
S 0 0.000000 0.0000 0.0000
H 1 1.000000 71.9600 0.0000
T 921 929.015717 53348.5009 48396.5200
661 691.691193 43809.9991 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3799 3877.256910 284142.0400 82568.1400