CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 2236 6522.500000 241168.0000 36.9748
Subtotal (Total Children Is Unduplicated) 2236 6522.500000 241168.0000 36.9748
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 14 14.000000 275.9400 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 16.000000 221.9200 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 14 14.000000 127.1200 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 16.000000 445.2800 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 50.1000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.000000 134.4000 22.4000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 182 337.000000 25275.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 103 179.000000 13425.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 54 93.000000 6975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 183 343.000000 19036.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 63.000000 4725.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 17 18.000000 918.9000 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 11 11.000000 561.5500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 4 4.000000 195.7600 48.9400
Subtotal (Total Children Is Unduplicated) 311 1156.500000 74842.2700 64.7145
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1114 9474.250000 473712.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 294 551.250000 27562.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 225 948.000000 67636.7900 71.3468
OCCT-97530GT-OT SESSION BY LICENSED OT 16 27.500000 1964.6000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 25 55.000000 3146.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 1.500000 85.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 265 1104.000000 78725.1500 71.3090
PHY-97110GT-PT SESSION BY LICENSED PT 13 9.750000 696.5400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 13 23.750000 1357.5500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 261 1325.250000 94657.4800 71.4261
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 24 32.750000 2339.6600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 12 28.500000 1630.2000 57.2000
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 5 7.750000 553.6600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 1447 13596.25000 754198.9500 55.4711
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Total 21275.250000 1070209.2200 50.3030
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Number of Children (Unduplicated) With at Least One Service 2433
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Center 10
Flag Claims Units Chgs Paid
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R 138 106.250000 4413.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1049 776.500000 30820.2500 9.2500
P 8539 6678.500000 277247.8600 287007.1000
D 19 18.750000 886.7200 0.0000
S 14 35.000000 1750.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5212 13660.250000 755091.3900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14971 21275.250000 1070209.2200 287016.3500