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
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 12.250000 453.2500 37.0000
Subtotal (Total Children Is Unduplicated) 4 12.250000 453.2500 37.0000
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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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 8.000000 450.0000 56.2500
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 6.000000 300.0000 50.0000
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 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 47 104.500000 7137.5000 68.3014
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 22.000000 1650.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 38 90.000000 5700.0000 63.3333
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 16 36.500000 2247.5000 61.5753
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 16.000000 888.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 42 81.000000 4560.8500 56.3068
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 14 15.000000 700.0000 46.6667
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 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 96 446.000000 28313.3000 63.4827
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 62 171.750000 8587.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 75 266.250000 13312.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 28.000000 1643.1200 58.6829
OCCT-97530GT-OT SESSION BY LICENSED OT 23 83.250000 5733.0600 68.8656
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 65 158.250000 11162.5000 70.5371
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 94 519.750000 34750.5400 66.8601
Subtotal (Total Children Is Unduplicated) 222 1406.000000 86811.0600 61.7433
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Total 1864.250000 115577.6100 61.9968
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Number of Children (Unduplicated) With at Least One Service 266
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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 25 42.250000 2388.1500 2240.9700
D 0 0.000000 0.0000 0.0000
S 4 4.000000 285.7600 0.0000
H 50 59.750000 4105.0200 0.0000
T 598 970.750000 60684.8900 55713.9400
477 787.500000 48113.7900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1154 1864.250000 115577.6100 57954.9100