CMS/EIP Fiscal Report Center: 57
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 1 3.750000 139.5000 37.2000
Subtotal (Total Children Is Unduplicated) 1 4.000000 148.8000 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 15.1900 15.1900
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 21.4600 21.4600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 16.1500 16.1500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 15.8400 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 63.6200 31.8100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 15.1900 15.1900
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 46.2800 23.1400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.000000 444.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 74.000000 5561.9600 75.1616
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 51 82.000000 6150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 10.500000 787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 33.500000 2512.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 109 182.500000 10137.5900 55.5484
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 21.500000 1193.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 11.000000 825.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 308.4600 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 153 472.500000 30314.1600 64.1570
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 124.000000 6212.0000 50.0968
OCCT-97530-OT SESSION BY LICENSED OT 15 105.000004 7583.8800 72.2274
OCCT-97530HM-OT SESSION BY OT ASST 4 32.000000 1843.2000 57.6000
PHY-97110HM-PT SESSION BY PT ASST 3 27.000000 1554.1200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 32.500000 2338.7000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 287.8400 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.000000 115.2000 57.6000
Subtotal (Total Children Is Unduplicated) 40 326.500004 19934.9400 61.0565
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Total 803.000004 50397.9000 62.7620
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Number of Children (Unduplicated) With at Least One Service 184
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Center 57
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 11 8.008426 550.2400 550.2400
D 11 11.000000 488.9400 0.0000
S 0 0.000000 0.0000 0.0000
H 195 314.000000 20554.0500 20446.3000
T 196 181.205609 11993.1400 11993.1400
245 288.785969 16811.5300 315.4800
Other 0 0.000000 0.0000 0.0000
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Total 658 803.000004 50397.9000 33305.1600