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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 10 12.750000 474.3000 37.2000
Subtotal (Total Children Is Unduplicated) 10 12.750000 474.3000 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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 25.000000 2023.5000 80.9400
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 19 32.500000 2437.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 12.970000 1122.9300 86.5790
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 17 29.000000 2175.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 24.500000 2025.0000 82.6531
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 26.500000 1470.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 26 45.000000 2486.5000 55.2556
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 81 231.970000 15614.5400 67.3128
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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 1137.602600 83048.3600 73.0030
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Number of Children (Unduplicated) With at Least One Service 212
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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 136 116.760000 16677.1900 11409.9100
D 535 546.150000 38261.7500 31.5700
S 0 0.000000 0.0000 0.0000
H 1 1.000000 71.9600 0.0000
T 259 262.073377 14835.5600 11599.9400
201 211.619223 13201.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1132 1137.602600 83048.3600 23041.4200