CMS/EIP Fiscal Report Center: 10
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/20/2020 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3129 9658.000000 357346.0000 37.0000
Subtotal (Total Children Is Unduplicated) 3129 9659.250000 357346.0000 36.9952
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 5 5.000000 96.8500 19.3700
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.5000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 87.4800 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 58.7400 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 172.3200 28.7200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.7100 13.7100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.000000 62.6700 20.8900
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.500000 187.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.500000 138.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 44.500000 3337.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 262 518.500000 38848.5000 74.9248
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 75 137.000000 10275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 14.500000 1087.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 110 195.000000 14586.0000 74.8000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 42.000000 2331.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 230 437.000000 24253.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.500000 787.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 98 171.500000 12862.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 2.000000 51.0500 25.5250
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 4 5.000000 204.2000 40.8400
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 6 7.000000 306.3000 43.7571
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 8.000000 357.3500 44.6688
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 10.000000 393.0700 39.3070
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 6 6.000000 306.3000 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 17 20.000000 921.4300 46.0715
Subtotal (Total Children Is Unduplicated) 438 1695.500000 114105.4200 67.2990
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 23.000000 9257.7500 402.5109
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 32 30.500000 1525.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 138 137.000000 6850.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 39 34.500000 862.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 63 76.500000 3825.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 176 216.000000 10800.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 21 30.250000 756.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 10 11.500000 575.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 22 31.750000 1550.5000 48.8346
CONOP-CONOP-CONSULT, OT, PHONE 1 3.000000 75.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 6.000000 300.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 90 91.000000 4550.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 26 27.500000 1375.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 148 177.500000 8875.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 8.000000 200.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 330 1753.750000 87687.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1044 9020.000000 451000.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 437 2880.000000 28800.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 101 334.750000 23600.7800 70.5027
OCCT-97530GT-OT SESSION BY LICENSED OT 181 833.500000 58535.0800 70.2281
OCCT-97530HM-OT SESSION BY OT ASST 11 69.500000 3718.0000 53.4964
OCCT-97530HMGT-OT SESSION BY OT ASST 6 33.000000 1887.6000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 0.750000 53.5800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 193 731.750000 52094.0400 71.1910
PHY-97110GT-PT SESSION BY LICENSED PT 234 933.500000 65289.8500 69.9409
PHY-97110HM-PT SESSION BY PT ASST 1 2.500000 142.9000 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.250000 71.4500 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 5 7.500000 535.8000 71.4400
SENS-V5264-EARMOLD 2 4.000000 72.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 153 578.000000 40756.5200 70.5130
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 344 2009.250000 141086.8600 70.2187
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.250000 14.3000 57.2000
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 5 13.000000 928.7200 71.4400
CMS/EIP Fiscal Report Center: 10
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/20/2020 Page: 2
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 138 183.500000 6789.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1793 20293.75000 1014441.4800 49.9879
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Total 31648.500000 1485892.9000 46.9499
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Number of Children (Unduplicated) With at Least One Service 3286
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Center 10
Flag Claims Units Chgs Paid
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R 464 352.250000 13355.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2644 1923.000000 77757.7500 0.0000
P 11511 15570.500000 679255.3600 678357.7450
D 105 73.750000 3007.2900 0.0000
S 117 210.750000 13593.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8286 13483.500000 696598.7500 0.0000
Other 23 34.750000 2325.2500 0.0000
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Total 23150 31648.500000 1485892.9000 678357.7450