CMS/EIP Fiscal Report Center: 10
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 Page: 1
List order: No List
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 1.000000 37.0000 37.0000
Subtotal (Total Children Is Unduplicated) 2 1.000000 37.0000 37.0000
-----------------------------------------------------------------------------------------------------------------------
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
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) 57 98.000000 3789.4200 38.6676
-----------------------------------------------------------------------------------------------------------------------
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
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
-----------------------------------------------------------------------------------------------------------------------
Total 20392.750000 1018267.9000 49.9328
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1801
-----------------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 4563 10712.500000 481466.3600 481091.9000
D 2 4.500000 295.0400 0.0000
S 29 49.750000 2532.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3148 9625.500000 533955.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7743 20392.750000 1018267.9000 481091.9000