CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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 7 7.000000 137.9100 19.7014
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 19.5900 19.5900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 9 9.000000 132.0300 14.6700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 76.1400 9.5175
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 11 11.000000 317.2400 28.8400
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 83.8700 83.8700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 58.3800 14.5950
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.000000 62.0700 20.6900
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 5 6.000000 255.2500 42.5417
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 5.000000 204.2000 40.8400
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 29 68.000000 2068.2300 30.4151
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 24.000000 1874.9600 78.1233
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 14.750000 737.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 72 389.500000 24605.6300 63.1723
OCCT-97530HM-OT SESSION BY OT ASST 2 3.500000 200.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 98 513.750000 34984.4000 68.0962
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 96 491.500000 32234.2000 65.5833
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.500000 28.6000 57.2000
Subtotal (Total Children Is Unduplicated) 193 1438.500000 94722.6500 65.8482
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Total 1506.500000 96790.8800 64.2488
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Number of Children (Unduplicated) With at Least One Service 207
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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 604 438.750000 23637.3300 23623.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
597 1067.750000 73153.5500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1201 1506.500000 96790.8800 23623.7500