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
Payclass Filters:GR
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 1331 3834.750000 141885.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1996 4803.750000 141885.7500 29.5365
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 40 41.000000 803.6700 19.6017
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 41 42.000000 612.1400 14.5748
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 41 43.000000 404.8700 9.4156
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 40 41.000000 1177.3900 28.7168
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 83.8700 83.8700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 15 15.000000 221.2500 14.7500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 17 18.000000 375.8400 20.8800
EXIT-EXIT-EXIT ASSESSMENT 1 1.500000 75.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 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 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 107 192.000000 14400.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 63.500000 4762.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 31.000000 2325.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 103 196.500000 10905.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 26.500000 1987.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 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 10 10.000000 510.5000 51.0500
Subtotal (Total Children Is Unduplicated) 199 764.500000 41194.1700 53.8838
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 27.000000 647.4300 23.9789
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 601 6260.000000 313000.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1964 22562.00000 225620.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 143 645.000000 45821.2700 71.0407
OCCT-97530HM-OT SESSION BY OT ASST 8 16.500000 943.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 188 936.750000 66902.5100 71.4198
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 2.000000 228.0000 114.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 235 1339.000000 95586.8000 71.3867
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.500000 6.9400 13.8800
Subtotal (Total Children Is Unduplicated) 2122 32642.25000 790498.9500 24.2170
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Total 38210.500000 973578.8700 25.4794
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Number of Children (Unduplicated) With at Least One Service 3048
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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 11534 32686.500000 790595.1500 790595.1500
D 5 6.000000 60.0000 0.0000
S 113 179.750000 4975.7200 80.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6731 5338.250000 177948.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18383 38210.500000 973578.8700 790675.1500