CMS/EIP Fiscal Report Center: 57
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 1 3.750000 139.5000 37.2000
Subtotal (Total Children Is Unduplicated) 1 4.000000 148.8000 37.2000
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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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.9200 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 63.6200 31.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 46.2800 23.1400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 20.500000 1642.1500 80.1049
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 15.000000 1184.8000 78.9867
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.000000 566.8600 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 24 41.500000 2451.3200 59.0680
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 6.000000 359.5200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 39.500000 3031.2700 76.7410
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 55.500000 4207.3500 75.8081
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 9 14.000000 1079.9000 77.1357
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 14.500000 1141.3200 78.7117
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 4.000000 305.9800 76.4950
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 65 108.500000 6152.1400 56.7018
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 21.500000 1219.7700 56.7335
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 12 19.000000 1070.5900 56.3468
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 386.6700 55.2386
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 7.000000 400.0700 57.1529
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 225.7400 56.4350
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 502.8900 55.8767
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 134 417.000000 27197.7200 65.2224
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 296.000000 15500.0000 52.3649
OCCT-97530-OT SESSION BY LICENSED OT 18 240.384910 18628.7600 77.4955
OCCT-97530GO-OT SESSION BY LICENSED OT 1 4.000000 325.2800 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 4 113.000006 7117.9200 62.9904
PHY-97110HM-PT SESSION BY PT ASST 3 35.500000 2122.7600 59.7961
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 46.000000 3436.5200 74.7070
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 23.500000 1873.5800 79.7268
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 3.500000 212.8800 60.8229
Subtotal (Total Children Is Unduplicated) 48 761.884916 49217.7000 64.5999
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Total 1182.884916 76564.2200 64.7267
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Number of Children (Unduplicated) With at Least One Service 168
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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 35 24.906404 1780.3400 1583.1200
D 20 20.000000 1360.3500 0.0000
S 0 0.000000 0.0000 0.0000
H 181 285.500000 19164.5700 19056.8500
T 400 358.293003 25307.5600 25307.5600
496 494.185509 28951.4000 960.0200
Other 0 0.000000 0.0000 0.0000
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Total 1132 1182.884916 76564.2200 46907.5500