CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2025 ending 03/31/2025 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
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-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 15.1900 15.1900
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 283.4300 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 8.500000 688.3300 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 8 13.500000 808.9200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 48.000000 3887.0400 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 61 98.500000 7976.5300 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 8.000000 647.8400 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 46.000000 3725.0800 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 7.500000 607.3500 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 115 199.000000 11924.0800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 11 17.000000 1018.6400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 485.8800 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 4.000000 232.4400 58.1100
Subtotal (Total Children Is Unduplicated) 143 470.000000 32830.7500 69.8527
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 37.000000 1998.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 57.500000 4675.9000 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 3 16.000000 1041.9200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 162.6400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 1 5.000000 325.6000 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 243.9600 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 243.9600 81.3200
Subtotal (Total Children Is Unduplicated) 24 123.500000 8691.9800 70.3804
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Total 593.500000 41522.7300 69.9625
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Number of Children (Unduplicated) With at Least One Service 163
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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 0 0.000000 0.0000 0.0000
D 4 4.000000 325.2800 0.0000
S 0 0.000000 0.0000 0.0000
H 166 269.500000 18707.5000 18607.7300
T 21 22.000000 1642.0300 1642.0300
219 298.000000 20847.9200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 410 593.500000 41522.7300 20249.7600