CMS/EIP Fiscal Report Center: 10
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 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
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.3700 19.3700
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.5800 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.7900 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.7200 28.7200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.8900 20.8900
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.500000 187.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 13.000000 975.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 99 227.500000 17062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 30 62.500000 4687.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 22 45.500000 3412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 12.500000 693.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 91 188.500000 10461.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.500000 187.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 68.000000 5100.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 2.000000 51.0500 25.5250
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 3.000000 102.1000 34.0333
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 2.000000 51.0500 25.5250
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 2.000000 51.0500 25.5250
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 6.000000 188.8700 31.4783
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 7.000000 257.7800 36.8257
Subtotal (Total Children Is Unduplicated) 148 667.000000 44844.0500 67.2325
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 2738.5800 2738.5800
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 13.000000 650.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 24.750000 1237.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 44.750000 2883.1800 64.4286
OCCT-97530GT-OT SESSION BY LICENSED OT 40 147.250000 9519.3800 64.6477
OCCT-97530HM-OT SESSION BY OT ASST 1 9.000000 257.4000 28.6000
PHY-97110-PT SESSION BY LICENSED PT 29 97.750000 6801.0800 69.5763
PHY-97110GT-PT SESSION BY LICENSED PT 55 191.250000 12469.8600 65.2019
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 105.750000 7018.9800 66.3733
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 55 216.750000 13065.6600 60.2799
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.250000 14.3000 57.2000
Subtotal (Total Children Is Unduplicated) 155 853.500000 56691.9200 66.4229
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Total 1520.500000 101535.9700 66.7780
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Number of Children (Unduplicated) With at Least One Service 287
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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 477 454.750000 30784.8300 30783.9500
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
586 1065.750000 70751.1400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1063 1520.500000 101535.9700 30783.9500