CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 10 68.000000 2529.6000 37.2000
Subtotal (Total Children Is Unduplicated) 10 68.250000 2538.9000 37.2000
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 56.1000 56.1000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 42.9200 21.4600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 16.1500 16.1500
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 24.2800 24.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 15.8400 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 95.4300 31.8100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 15.1900 15.1900
EXIT-EXIT-COS Exit 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 283.4300 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 4.000000 308.9700 77.2425
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.000000 392.9400 78.5880
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.500000 271.4700 77.5629
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 2.500000 202.4500 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.000000 286.3400 57.2680
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 59.9200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 37.000000 2798.9200 75.6465
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 36 62.500000 4753.2800 76.0525
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 52.000000 3941.8600 75.8050
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 36 64.500000 4864.4100 75.4172
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 16.000000 1200.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 34.000000 2565.6000 75.4588
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 46.000000 2575.1000 55.9804
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 39 71.000000 4032.5400 56.7963
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 3.000000 174.3300 58.1100
Subtotal (Total Children Is Unduplicated) 136 424.500000 29177.4700 68.7337
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EI Services,Class #03
AUD-92630-AUD REHAB PRELING HEARING LOSS 1 1.000000 47.3500 47.3500
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 342.500000 18199.0000 53.1358
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 48.000000 2548.0000 53.0833
OCCT-97530-OT SESSION BY LICENSED OT 11 104.250000 6823.9400 65.4575
OCCT-97530GO-OT SESSION BY LICENSED OT 2 3.500000 265.9000 75.9714
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 7.750000 306.5600 39.5561
OCCT-97530GT-OT SESSION BY LICENSED OT 6 86.500000 6003.2200 69.4014
OCCT-97530HM-OT SESSION BY OT ASST 2 21.500000 1291.1200 60.0521
OCCT-97530HMGT-OT SESSION BY OT ASST 3 23.250000 1457.6100 62.6929
PHY-97110-PT SESSION BY LICENSED PT 17 480.250000 33654.5800 70.0772
PHY-97110GT-PT SESSION BY LICENSED PT 6 39.250000 2407.7300 61.3434
PHY-97110HM-PT SESSION BY PT ASST 8 100.500000 5805.7200 57.7684
PHY-97110HMGT-PT SESSION BY PT ASST 3 19.750000 803.2800 40.6724
SENS-V5264-EARMOLD 4 9.000000 163.1700 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 49 524.500000 38870.2200 74.1091
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 27 241.000000 17970.6700 74.5671
Subtotal (Total Children Is Unduplicated) 109 2053.500000 136643.0700 66.5415
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Total 2546.250000 168359.4400 66.1205
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Number of Children (Unduplicated) With at Least One Service 231
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Center 06
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 1505 1411.250000 91738.3000 91738.3000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1104 1135.000000 76621.1400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2609 2546.250000 168359.4400 91738.3000