CMS/EIP Fiscal Report Center: 57
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
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-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 31.8100 31.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 23.1400 23.1400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 12.500000 1012.2500 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 283.4300 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 9 15.500000 928.7600 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 6.000000 359.5200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 40.500000 3279.6900 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.500000 364.4100 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 41 69.500000 5628.1100 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 202.4500 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 21.500000 1741.0700 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 11.000000 890.7800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 74 129.500000 7759.6400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 12 19.500000 1168.4400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 13.500000 1093.2300 80.9800
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 290.5500 58.1100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 522.9900 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 116.2200 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 232.4400 58.1100
Subtotal (Total Children Is Unduplicated) 120 383.500000 26596.2000 69.3512
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 88.000000 4752.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 81.000000 6622.3000 81.7568
OCCT-97530HM-OT SESSION BY OT ASST 3 25.000000 1628.0000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 1 5.000000 406.6000 81.3200
PHY-97110HM-PT SESSION BY PT ASST 2 23.000000 1497.7600 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 6.000000 487.9200 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 11.000000 894.5200 81.3200
Subtotal (Total Children Is Unduplicated) 31 239.000000 16289.1000 68.1552
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Total 622.500000 42885.3000 68.8920
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Number of Children (Unduplicated) With at Least One Service 144
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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 26 18.657438 1393.1500 1195.9300
D 7 7.000000 569.2400 0.0000
S 0 0.000000 0.0000 0.0000
H 129 207.500000 14547.6200 14439.8700
T 155 149.790341 10744.7200 10744.7200
185 239.552221 15630.5700 120.0000
Other 0 0.000000 0.0000 0.0000
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Total 502 622.500000 42885.3000 26500.5200