CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 971 917.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3606 10484.50000 387908.0000 36.9982
Subtotal (Total Children Is Unduplicated) 3610 11401.50000 387908.0000 34.0225
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 88 95.000000 1862.7900 19.6083
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 19.5900 19.5900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 94 102.000000 1489.1400 14.5994
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 88 96.000000 906.3800 9.4415
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 96 104.000000 2990.2700 28.7526
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 83.8700 83.8700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 28 28.000000 411.9300 14.7118
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 43 47.000000 975.8500 20.7628
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 19.500000 1462.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 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 13 25.500000 1415.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 522 969.500000 72712.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 218 385.500000 28883.2500 74.9241
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 123 200.500000 15037.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 557 1070.000000 59385.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 63 141.500000 10612.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 9 11.000000 510.5000 46.4091
OCTH-97167-OT EVAL HIGH COMPLEXITY 19 21.000000 1021.0000 48.6190
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 9 10.000000 510.5000 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 21 21.000000 1072.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 15 15.000000 765.7500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 853 3386.000000 203664.1600 60.1489
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 12 118.000000 11725.3800 99.3676
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 280 255.500000 12775.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 7 6.000000 150.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 118 130.500000 6525.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 22 21.500000 537.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 12 16.000000 800.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 91 118.500000 5925.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 6.000000 150.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 181 223.000000 11150.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1751 17465.25000 873262.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1932 22040.00000 220400.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 352 1730.750000 120309.5200 69.5129
OCCT-97530HM-OT SESSION BY OT ASST 18 58.750000 3360.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 439 2148.500000 151629.7800 70.5747
PHY-97110HM-PT SESSION BY PT ASST 12 15.500000 885.9800 57.1600
SENS-V5264-EARMOLD 2 4.000000 72.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 505 2916.500000 205319.0000 70.3991
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 5.000000 286.0000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 3 5.000000 69.4000 13.8800
Subtotal (Total Children Is Unduplicated) 2300 47289.25000 1625457.5600 34.3727
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Total 62076.750000 2217029.7200 35.7143
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Number of Children (Unduplicated) With at Least One Service 3894
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Center 10
Flag Claims Units Chgs Paid
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R 189 163.750000 6058.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3618 2975.000000 122719.5000 18.5000
P 17052 37304.750000 1005208.0300 1004001.1080
D 49 50.500000 1450.3400 0.0000
S 141 298.000000 8870.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
11849 21284.250000 1072704.3000 0.0000
Other 1 0.500000 18.5000 0.0000
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Total 32899 62076.750000 2217029.7200 1004019.6080