CMS/EIP Fiscal Report Center: 07
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 5 4.750000 175.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 57 130.000000 4819.2500 37.0712
Subtotal (Total Children Is Unduplicated) 57 136.000000 4995.0000 36.7279
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.000000 55.4800 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 45.4000 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 111.3200 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 22.4000 22.4000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 21.000000 1575.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 38.013300 2851.0000 75.0001
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 510.5000 51.0500
Subtotal (Total Children Is Unduplicated) 45 87.013300 5340.9500 61.3808
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 48.000000 2400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 47.750000 3411.2600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 5 33.500000 2393.2400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 58 258.000000 18431.5200 71.4400
Subtotal (Total Children Is Unduplicated) 81 387.250000 26636.0200 68.7825
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Total 610.263300 36971.9700 60.5836
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Number of Children (Unduplicated) With at Least One Service 168
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Center 07
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 145 377.763300 25116.9100 24902.5900
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 34.500000 2587.5000 0.0000
T 0 0.000000 0.0000 0.0000
192 196.000000 9117.5600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 356 610.263300 36971.9700 24902.5900