CMS/EIP Fiscal Report Center: 10
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1056 969.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3564 10628.25000 393134.2500 36.9896
Subtotal (Total Children Is Unduplicated) 3564 11597.25000 393134.2500 33.8989
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 54 55.000000 1078.7100 19.6129
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 57 59.000000 877.8900 14.8795
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 54 58.000000 537.4400 9.2662
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 55 56.000000 1612.4500 28.7938
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 83.8700 83.8700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 18 18.000000 265.1800 14.7322
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 24 25.000000 520.6700 20.8268
EXIT-EXIT-EXIT ASSESSMENT 1 1.500000 75.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 48.500000 3637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 11.500000 862.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 56.000000 3108.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 527 1010.500000 75787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 171 308.000000 23126.2500 75.0852
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 114 191.500000 14362.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 506 1008.000000 55944.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 83 193.000000 14475.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 10 12.000000 510.5000 42.5417
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 7.000000 306.3000 43.7571
SPCH-92521-EVAL OF SPEECH FLUENCY 1 2.000000 51.0500 25.5250
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 16 16.000000 816.8000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 18 18.000000 918.9000 51.0500
Subtotal (Total Children Is Unduplicated) 783 3174.500000 200115.9500 63.0386
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 58.000000 4020.0200 69.3107
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 306 285.500000 14275.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 11 9.750000 243.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 160 198.500000 9925.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 19 16.000000 399.9500 24.9969
CONOF-CONOF-CONSULT, OT, FACE TO FACE 20 23.000000 1150.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 70 89.750000 4487.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 4 3.000000 75.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 185 220.000000 11000.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 7 5.500000 137.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1799 18373.00000 918600.0000 49.9973
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1964 22562.00000 225620.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 296 1499.000000 103570.1400 69.0928
OCCT-97530HM-OT SESSION BY OT ASST 20 43.250000 2473.9000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 385 1962.000000 138278.0200 70.4781
PHY-97110HM-PT SESSION BY PT ASST 5 7.750000 442.9900 57.1600
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 2.000000 228.0000 114.0000
SENS-V5264-EARMOLD 2 4.000000 72.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 400 2359.250000 167110.5100 70.8320
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 6.500000 371.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 6 8.500000 117.9800 13.8800
Subtotal (Total Children Is Unduplicated) 2266 47736.75000 1602611.5600 33.5719
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Total 62508.500000 2195861.7600 35.1290
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Number of Children (Unduplicated) With at Least One Service 3928
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Center 10
Flag Claims Units Chgs Paid
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R 114 81.750000 3024.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2859 2195.750000 86692.5000 0.0000
P 18753 38870.250000 1060018.5200 1059833.0500
D 7 8.000000 160.0000 0.0000
S 149 268.250000 10086.8000 80.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
12074 21084.500000 1035879.1900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 33956 62508.500000 2195861.7600 1059913.0500