CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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 8 33.500000 1246.2000 37.2000
Subtotal (Total Children Is Unduplicated) 8 33.500000 1246.2000 37.2000
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 56.1000 56.1000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 42.9200 21.4600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 16.1500 16.1500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.9200 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 31.8100 31.8100
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 58.000000 4275.0000 73.7069
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 52 87.000000 6525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 51 78.500000 5887.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 61 107.000000 8025.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 29.500000 2175.0000 73.7288
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 25 43.500000 3233.2500 74.3276
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 63.000000 3468.7500 55.0595
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 58 103.500000 5783.2500 55.8768
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 181 588.500000 40389.7600 68.6317
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EI Services,Class #03
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 1.000000 47.3500 47.3500
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 74.000000 3700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 6 16.000000 800.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 37.500000 2371.6700 63.2445
OCCT-97530GO-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 4 24.000000 1583.1200 65.9633
OCCT-97530HM-OT SESSION BY OT ASST 1 1.500000 86.4000 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 8.250000 497.0900 60.2533
PHY-97110-PT SESSION BY LICENSED PT 16 158.500000 9551.8800 60.2642
PHY-97110GT-PT SESSION BY LICENSED PT 5 29.500000 1672.8700 56.7075
PHY-97110HM-PT SESSION BY PT ASST 5 37.000000 2034.7600 54.9935
PHY-97110HMGT-PT SESSION BY PT ASST 3 11.000000 643.9600 58.5418
SENS-V5264-EARMOLD 3 5.000000 90.6500 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 48 250.750000 16582.4500 66.1314
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 21 106.750000 7362.2200 68.9669
Subtotal (Total Children Is Unduplicated) 104 764.750000 47312.2600 61.8663
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Total 1386.750000 88948.2200 64.1415
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Number of Children (Unduplicated) With at Least One Service 272
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Center 06
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 601 558.000000 33405.0500 33405.0500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
642 828.750000 55543.1700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1243 1386.750000 88948.2200 33405.0500