CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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 0.750000 27.9000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 8.250000 306.9000 37.2000
Subtotal (Total Children Is Unduplicated) 4 9.000000 334.8000 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 16.1500 16.1500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 23.7600 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 95.4300 31.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 23.1400 23.1400
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 359.5200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.500000 919.3100 79.9400
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 16.500000 1336.1700 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 25.500000 2041.0700 80.0420
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 21 40.500000 3722.3400 91.9096
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 971.7600 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 485.8800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 46.000000 2756.3200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 24 47.000000 2816.2400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 16.000000 1271.7600 79.4850
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 323.9200 80.9800
Subtotal (Total Children Is Unduplicated) 85 244.500000 17566.0400 71.8447
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 9.000000 655.2100 72.8011
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 100 420.000000 22748.0000 54.1619
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 37 71.750000 3874.5000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 268.380000 7778.0800 28.9816
OCCT-97530GO-OT SESSION BY LICENSED OT 13 40.000000 3215.3600 80.3840
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 17.000000 1382.4400 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 5 8.500000 691.2200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 2 10.000000 651.2000 65.1200
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 130.2400 65.1200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 1 5.000000 406.6000 81.3200
PHY-97110-PT SESSION BY LICENSED PT 24 80.870000 6678.9700 82.5890
PHY-97110GT-PT SESSION BY LICENSED PT 4 3.870000 314.8100 81.3463
PHY-97110TL-PT SESSION BY LICENSED PT 1 5.000000 406.6000 81.3200
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 197.590000 16973.5600 85.9029
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 11 21.000000 1886.7300 89.8443
Subtotal (Total Children Is Unduplicated) 207 1164.960000 67979.7800 58.3537
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Total 1418.460000 85880.6200 60.5450
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Number of Children (Unduplicated) With at Least One Service 262
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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 58 67.510000 6499.1500 4796.0300
D 219 399.450000 18330.5200 0.0000
S 1 2.000000 161.9600 0.0000
H 14 15.000000 1202.9200 0.0000
T 666 689.860000 41609.9900 41609.9900
246 242.640000 17914.1200 0.0000
Other 1 2.000000 161.9600 0.0000
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Total 1205 1418.460000 85880.6200 46406.0200