CMS/EIP Fiscal Report Center: 54
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 2 1.000000 37.2000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 10 7.500000 279.0000 37.2000
Subtotal (Total Children Is Unduplicated) 11 8.500000 316.2000 37.2000
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Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 116.8300 116.8300
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 7.000000 113.0500 16.1500
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 24.2800 24.2800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 12.000000 95.0400 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 10 10.000000 318.1000 31.8100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 30.3800 15.1900
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 23.1400 23.1400
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 271.4700 77.5629
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 461.6800 57.7100
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 13.500000 773.5600 57.3007
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.000000 695.9300 77.3256
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 23 44.000000 3556.2700 80.8243
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 15.500000 1174.4600 75.7716
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 31.500000 1783.6100 56.6225
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 39.500000 2234.2400 56.5630
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 12.000000 923.9200 76.9933
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 311.9600 77.9900
Subtotal (Total Children Is Unduplicated) 77 244.500000 15205.7600 62.1912
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 2 2.000000 95.8800 47.9400
ASST-ASST-ASSISTIVE TECHNOLOGY 16 29.000000 2945.0900 101.5548
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 123 1164.250000 61522.5000 52.8430
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 70 193.250000 10170.5000 52.6287
OCCT-97530-OT SESSION BY LICENSED OT 46 464.430000 24436.1900 52.6154
OCCT-97530GO-OT SESSION BY LICENSED OT 12 80.000000 6440.0800 80.5010
OCCT-97530GOGT-OT SESSION BY LICENSED OT 7 26.000000 2076.8800 79.8800
OCCT-97530GT-OT SESSION BY LICENSED OT 16 21.000000 1683.4400 80.1638
OCCT-97530HM-OT SESSION BY OT ASST 3 39.000000 3203.8400 82.1497
OCCT-97530HMGT-OT SESSION BY OT ASST 2 7.000000 455.8400 65.1200
OCCT-97530TL-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
OCCT-97530TLGO-OT SESSION BY LICENSED OT 4 22.740000 1842.9000 81.0422
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 1 0.740000 53.8600 72.7838
PHY-97110-PT SESSION BY LICENSED PT 28 238.620000 18835.6200 78.9356
PHY-97110GT-PT SESSION BY LICENSED PT 11 12.870000 1009.2500 78.4188
SENS-V5261-BEHIND EAR DIGITAL BINAURAL HEARING AID 1 1.000000 980.7400 980.7400
SENS-V5264-EARMOLD 2 6.000000 108.7800 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 670.140000 59249.3000 88.4133
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 22 69.000000 6201.9900 89.8839
TRAV-TRAVS-Travel by mile 1 10.000000 4.4500 0.4450
Subtotal (Total Children Is Unduplicated) 246 3064.040000 201754.9700 65.8461
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Total 3317.040000 217276.9300 65.5033
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Number of Children (Unduplicated) With at Least One Service 264
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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 204 187.230000 24200.7300 16533.5500
D 587 748.060000 43914.3200 0.0000
S 1 0.250000 9.3000 0.0000
H 38 38.000000 3041.5600 0.0000
T 1721 1696.610000 99831.2700 98611.4700
686 642.890000 45963.8300 0.0000
Other 4 4.000000 315.9200 0.0000
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Total 3241 3317.040000 217276.9300 115145.0200