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
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 971 917.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1320 3615.250000 133745.7500 36.9949
Subtotal (Total Children Is Unduplicated) 1949 4532.250000 133745.7500 29.5098
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 81 88.000000 1724.8800 19.6009
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 85 93.000000 1357.1100 14.5926
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 80 88.000000 830.2400 9.4345
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 85 93.000000 2673.0300 28.7423
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 24 24.000000 353.5500 14.7313
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 40 44.000000 913.7800 20.7677
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 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 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 96 170.500000 12787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 58.000000 4350.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 43.500000 3262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 102 180.500000 10017.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 31.000000 2325.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 612.6000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 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 10 10.000000 510.5000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 253 963.000000 43293.6900 44.9571
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 63.000000 6835.9600 108.5073
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 585 5825.000000 291250.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1932 22040.00000 220400.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 132 640.250000 45701.6500 71.3809
OCCT-97530HM-OT SESSION BY OT ASST 3 13.000000 743.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 159 797.750000 56884.4200 71.3061
PHY-97110HM-PT SESSION BY PT ASST 2 3.500000 200.0600 57.1600
SENS-V5264-EARMOLD 2 4.000000 72.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 245 1375.500000 98245.4100 71.4252
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.500000 143.0000 57.2000
Subtotal (Total Children Is Unduplicated) 2093 31546.50000 758613.6000 24.0475
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Total 37041.750000 935653.0400 25.2594
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Number of Children (Unduplicated) With at Least One Service 3035
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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 1 0.500000 18.5000 0.0000
P 10268 31762.000000 762741.4000 762741.4000
D 41 40.750000 1089.5900 0.0000
S 107 212.000000 4570.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6224 5026.500000 167233.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16641 37041.750000 935653.0400 762741.4000