CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2024 ending 06/30/2024 Date of Report:04/12/2025 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 9 11.750000 437.1000 37.2000
Subtotal (Total Children Is Unduplicated) 9 11.750000 437.1000 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-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.6800 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 44.0500 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 144.6000 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 41.4300 13.8100
AUDE-92652-AEP THRSHLD EST MLT FREQ I&R 2 2.000000 150.2600 75.1300
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 21.500000 1761.0000 81.9070
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 27.500000 2062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 12.500000 1087.5000 87.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 9 17.000000 1275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.500000 787.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 15.500000 1350.0000 87.0968
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 23.500000 1304.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 16 29.000000 1598.5000 55.1207
Subtotal (Total Children Is Unduplicated) 60 174.000000 11637.1100 66.8799
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EI Services,Class #03
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 198.500000 9925.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 21 30.000000 1500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 171.692600 12795.2000 74.5239
OCCT-97530GT-OT SESSION BY LICENSED OT 10 28.000000 3071.3600 109.6914
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.500000 107.9400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 32 228.890000 20848.8600 91.0868
PHY-97110GT-PT SESSION BY LICENSED PT 5 3.750000 269.8500 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 5.000000 695.8800 139.1760
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 188.050000 13994.4200 74.4186
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 32.500000 3413.1700 105.0206
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 287.8400 71.9600
Subtotal (Total Children Is Unduplicated) 158 892.882600 66959.5200 74.9925
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Total 1078.632600 79033.7300 73.2722
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Number of Children (Unduplicated) With at Least One Service 191
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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 135 116.290000 16641.7600 11374.4800
D 508 503.150000 35241.5000 31.5700
S 0 0.000000 0.0000 0.0000
H 1 1.000000 71.9600 0.0000
T 258 260.073377 14724.5600 11599.9400
192 198.119223 12353.9500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1094 1078.632600 79033.7300 23005.9900