CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 886 816.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1315 3852.000000 142524.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1868 4668.750000 142524.0000 30.5272
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 29 30.000000 588.6600 19.6220
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 33 34.000000 491.5800 14.4582
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 26 27.000000 252.9600 9.3689
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 32 33.000000 942.6300 28.5645
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 14 14.000000 209.0500 14.9321
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 7 8.000000 170.6500 21.3313
EXIT-EXIT-EXIT ASSESSMENT 2 8.000000 400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 11.500000 862.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 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 7 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 92 167.000000 12525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 60.500000 4537.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 48.000000 3600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 87 167.000000 9268.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 46.000000 3450.0000 75.0000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 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-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 12 12.000000 612.6000 51.0500
Subtotal (Total Children Is Unduplicated) 186 712.000000 40462.3200 56.8291
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1596.0000 1596.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 233 240.000000 12000.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 14 11.000000 550.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 17 12.500000 312.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 204 243.000000 12150.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 6 6.000000 300.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 12 15.500000 387.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 21.000000 1050.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 1 2.000000 100.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 3.000000 75.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 99 100.500000 5025.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 193 209.500000 10475.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 10 10.000000 500.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 6 7.750000 193.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 547 4672.500000 233625.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 208 431.750000 21587.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1885 19980.00000 199800.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 135 680.250000 48484.0300 71.2738
OCCT-97530GT-OT SESSION BY LICENSED OT 21 19.500000 1337.5800 68.5938
OCCT-97530HM-OT SESSION BY OT ASST 3 4.500000 257.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 159 832.750000 59386.2300 71.3134
PHY-97110GT-PT SESSION BY LICENSED PT 23 16.750000 1196.6200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 14.750000 843.1100 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 235 1567.250000 111911.2800 71.4061
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 63 86.000000 6143.8400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 42 34.250000 1267.2500 37.0000
Subtotal (Total Children Is Unduplicated) 2033 29225.00000 730651.0300 25.0009
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Total 34605.750000 913637.3500 26.4013
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Number of Children (Unduplicated) With at Least One Service 2929
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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 10518 29268.000000 731212.0000 731212.0000
D 26 25.000000 1178.7200 0.0000
S 98 134.000000 3765.1300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6540 5031.250000 167491.5000 0.0000
Other 76 147.500000 9990.0000 0.0000
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Total 17258 34605.750000 913637.3500 731212.0000