CMS/EIP Fiscal Report Center: 54
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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 3.250000 120.9000 37.2000
Subtotal (Total Children Is Unduplicated) 4 3.500000 130.2000 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 23.7600 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 95.4300 31.8100
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 311.9600 77.9900
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.900000 967.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 22.500000 1687.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 28 53.400000 4005.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 21.500000 1624.4600 75.5563
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 42.500000 2358.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 30 57.500000 3191.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 18.000000 1350.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 623.9200 77.9900
Subtotal (Total Children Is Unduplicated) 94 279.300000 18441.5300 66.0277
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 8.000000 1421.1200 177.6400
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 108 445.750000 22387.5000 50.2243
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 43 79.250000 3982.5000 50.2524
OCCT-97530-OT SESSION BY LICENSED OT 38 133.550000 11566.2500 86.6061
OCCT-97530GO-OT SESSION BY LICENSED OT 3 3.000000 215.8800 71.9600
OCCT-97530GOGT-OT SESSION BY LICENSED OT 2 4.000000 287.8400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 8 12.000000 951.5600 79.2967
OCCT-97530TL-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
OCCT-97530TLGO-OT SESSION BY LICENSED OT 2 4.740000 379.1400 79.9873
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 1 0.740000 53.8600 72.7838
PHY-97110-PT SESSION BY LICENSED PT 21 71.750000 5163.1300 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 143.9200 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 2.000000 143.9200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 39 191.000000 16681.4400 87.3374
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 14 17.500000 1456.6500 83.2371
TRAV-TRAVS-Travel by mile 1 10.000000 4.4500 0.4450
Subtotal (Total Children Is Unduplicated) 218 990.280000 65177.0000 65.8167
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Total 1273.080000 83748.7300 65.7843
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Number of Children (Unduplicated) With at Least One Service 270
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Center 54
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 91 78.080000 10791.6300 6612.2500
D 285 326.000000 23667.9200 0.0000
S 0 0.000000 0.0000 0.0000
H 6 8.500000 628.3800 0.0000
T 678 734.090000 40774.7700 40774.7700
128 126.410000 7886.0300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1188 1273.080000 83748.7300 47387.0200