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: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 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 3 6.000000 473.9200 78.9867
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 433.4300 78.8055
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 283.4300 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 283.4300 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 581.5200 58.1520
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 17.500000 1004.4000 57.3943
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 6 10.000000 770.9300 77.0930
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.900000 667.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 17.000000 1286.9600 75.7035
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 27 50.400000 4045.2400 80.2627
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 598.3800 79.7840
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 17.500000 1324.4600 75.6834
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 41.000000 2337.3800 57.0093
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 27 50.500000 2860.2100 56.6378
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1085.8800 77.5629
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 473.9200 78.9867
Subtotal (Total Children Is Unduplicated) 102 310.800000 19843.7700 63.8474
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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 17 22.000000 1755.4000 79.7909
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) 247 3065.040000 201826.9300 65.8481
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Total 3384.340000 221986.9000 65.5924
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Number of Children (Unduplicated) With at Least One Service 289
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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 207 190.110000 24416.7300 16749.5500
D 601 770.480000 45616.4400 0.0000
S 1 0.250000 9.3000 0.0000
H 39 40.000000 3203.5200 0.0000
T 1738 1729.110000 101865.7700 100645.9700
690 650.390000 46559.2200 0.0000
Other 4 4.000000 315.9200 0.0000
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Total 3280 3384.340000 221986.9000 117395.5200