CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 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-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 6.000000 300.0000 50.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 4.000000 150.0000 37.5000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 31 72.000000 4650.0000 64.5833
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 12.000000 750.0000 62.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 15 30.000000 1665.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.0500 51.0250
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 10 11.000000 500.0000 45.4545
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 73 182.000000 11086.3500 60.9140
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 47 117.000000 5850.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 63 235.250000 11762.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 25.000000 1428.8000 57.1520
OCCT-97530GT-OT SESSION BY LICENSED OT 18 64.750000 4411.4200 68.1300
OCCT-97530HM-OT SESSION BY OT ASST 6 10.000000 572.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 7 31.750000 1816.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 19 44.500000 2696.8600 60.6036
PHY-97110GT-PT SESSION BY LICENSED PT 21 88.500000 5500.8800 62.1568
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 1000.0000 500.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 48 104.000000 7286.8800 70.0662
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 68 372.500000 24539.6400 65.8782
Subtotal (Total Children Is Unduplicated) 184 1097.250000 66901.0800 60.9716
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Total 1279.250000 77987.4300 60.9634
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Number of Children (Unduplicated) With at Least One Service 219
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Center 52
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 1 0.750000 53.5800 98.3200
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 384 734.500000 45605.2500 45605.2500
289 544.000000 32328.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 674 1279.250000 77987.4300 45703.5700