CMS/EIP Fiscal Report Center: 10
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
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 28 34.000000 729.6400 21.4600
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 26.0400 26.0400
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 28 34.000000 549.1000 16.1500
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.2300 23.2300
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 30 37.000000 301.8900 8.1592
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 28 37.000000 1049.7300 28.3711
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 29 35.000000 920.0300 26.2866
AUDE-V5010-ASSESSMENT FOR HEARING AID 3 4.000000 135.9600 33.9900
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 4.000000 463.2400 115.8100
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 35 73.000000 5785.9600 79.2597
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 10.000000 769.3100 76.9310
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 18.500000 1498.1300 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 27 55.000000 3218.2500 58.5136
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 323.9200 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 131 260.000000 19861.7900 76.3915
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 12.500000 937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 28.500000 2200.2900 77.2032
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 53.500000 4072.3000 76.1178
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 101 203.500000 11535.1400 56.6837
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 44.500000 3364.4100 75.6047
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.500000 337.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 31 40.000000 2199.2900 54.9823
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 31 40.000000 1811.2700 45.2818
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 13.3500 13.3500
PSTH-97161-PT EVAL LOW COMPLEXITY 25 34.000000 1850.6300 54.4303
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 6.000000 174.3300 29.0550
SPCH-92521-EVAL OF SPEECH FLUENCY 71 82.000000 4458.7100 54.3745
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 10.000000 482.7900 48.2790
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 31 357.000000 19705.8500 55.1985
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 6.000000 348.6600 58.1100
Subtotal (Total Children Is Unduplicated) 327 1538.500000 89651.8700 58.2723
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 20.000000 24611.1200 1230.5560
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 72.000000 3852.0000 53.5000
OCCT-97530-OT SESSION BY LICENSED OT 254 3597.000000 267769.9600 74.4426
OCCT-97530GO-OT SESSION BY LICENSED OT 5 9.000000 731.8800 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 2 4.500000 333.1800 74.0400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 7.000000 522.4400 74.6343
OCCT-97530HM-OT SESSION BY OT ASST 48 497.750000 28869.3000 57.9996
PHY-97110-PT SESSION BY LICENSED PT 234 3899.000000 288526.1200 74.0000
PHY-97110GT-PT SESSION BY LICENSED PT 2 7.000000 481.7800 68.8257
PHY-97110HM-PT SESSION BY PT ASST 15 188.500000 11757.2500 62.3727
SENS-V5050-IN EAR MONAURAL HEARING AID 3 3.000000 688.8300 229.6100
SENS-V5264-EARMOLD 4 7.000000 126.9100 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 392 5895.000000 448891.0700 76.1478
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 16 172.250000 13173.5100 76.4790
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 63.500000 3015.3000 47.4850
Subtotal (Total Children Is Unduplicated) 557 14442.50000 1093350.6500 75.7037
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Total 15981.000000 1183002.5200 74.0256
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Number of Children (Unduplicated) With at Least One Service 709
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Center 10
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 15829 10166.750000 751043.3600 751045.7100
D 25 25.000000 929.9600 0.0000
S 16 8.750000 676.6300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9341 5780.500000 430352.5700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 25211 15981.000000 1183002.5200 751045.7100