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
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 1 1.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1101 3424.000000 126688.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1101 3425.250000 126688.0000 36.9865
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.000000 77.4800 19.3700
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.5000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.000000 72.9000 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 48.9500 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 143.6000 28.7200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.7100 13.7100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 41.7800 20.8900
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 29 56.500000 4237.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 14.000000 1050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 21 34.500000 2587.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 26 49.500000 2747.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 15.000000 1125.0000 75.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
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 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 82 239.000000 14776.9700 61.8283
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 19.000000 5879.6300 309.4542
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 75 386.000000 19300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 382 3372.500000 168625.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 437 2880.000000 28800.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 38 101.000000 7215.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 87 369.250000 26369.2200 71.4129
OCCT-97530HM-OT SESSION BY OT ASST 2 8.000000 457.6000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 8.500000 486.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 63 260.250000 18592.2600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 97 416.250000 29608.9200 71.1325
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.250000 71.4500 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 1.500000 107.1600 71.4400
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 61 223.750000 15984.7000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 163 1105.750000 78959.7800 71.4083
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 2.500000 178.6000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 138 183.500000 6789.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1186 10222.00000 449580.7100 43.9817
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Total 13886.250000 591045.6800 42.5634
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Number of Children (Unduplicated) With at Least One Service 1771
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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 4 2.000000 74.0000 0.0000
P 4084 10244.000000 449849.1400 449964.8900
D 21 21.750000 933.2900 0.0000
S 24 29.750000 1532.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5087 3532.250000 134770.5000 0.0000
Other 35 56.500000 3886.5000 0.0000
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Total 9255 13886.250000 591045.6800 449964.8900