CMS/EIP Fiscal Report Center: 10
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:MED
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 1959 4969.000000 184921.2000 37.2150
Subtotal (Total Children Is Unduplicated) 1959 4969.000000 184921.2000 37.2150
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.000000 85.8400 21.4600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.000000 64.6000 16.1500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 31.6800 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 127.2400 31.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 4.000000 92.5600 23.1400
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.3200 45.3200
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 21.000000 1575.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH 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 5 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 321 584.500000 43924.4600 75.1488
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 24 45.000000 3375.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 58 95.000000 7125.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 64 107.000000 8062.5000 75.3505
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 239 421.000000 23337.7500 55.4341
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 130.500000 9848.9200 75.4707
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 205.6400 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 10 10.000000 514.1000 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 13 13.000000 668.3300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 9.000000 483.2400 53.6933
Subtotal (Total Children Is Unduplicated) 420 1510.500000 102623.2000 67.9399
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 774 7290.000000 365496.0000 50.1366
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 310 2071.500000 106137.0000 51.2368
OCCT-97530-OT SESSION BY LICENSED OT 180 1020.750000 74115.3900 72.6088
OCCT-97530GO-OT SESSION BY LICENSED OT 3 4.500000 337.8600 75.0800
OCCT-97530GT-OT SESSION BY LICENSED OT 4 7.500000 539.7000 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 40 223.000000 12844.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 235 1187.750000 86678.8100 72.9773
PHY-97110GT-PT SESSION BY LICENSED PT 3 1.500000 107.9400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 22 91.000000 5266.7600 57.8765
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 229.6100 229.6100
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 231 1420.500000 102846.3000 72.4015
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 40.750000 3091.4900 75.8648
Subtotal (Total Children Is Unduplicated) 1318 13361.75000 757734.7900 56.7092
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Total 19841.250000 1045279.1900 52.6821
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Number of Children (Unduplicated) With at Least One Service 2219
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Center 10
Flag Claims Units Chgs Paid
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R 215 174.500000 6491.4000 0.0000
U 0 0.000000 0.0000 0.0000
B 6545 5943.250000 265302.0300 0.0000
P 45 73.750000 4688.1500 50.0000
D 1 0.250000 9.3000 0.0000
S 5 2.500000 158.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
16203 13623.000000 767737.2100 0.0000
Other 40 24.000000 892.8000 0.0000
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Total 23054 19841.250000 1045279.1900 50.0000