CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 Page: 1
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 495 300.250000 11036.5000 36.7577
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 3.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 755 2614.250000 96597.7500 36.9505
Subtotal (Total Children Is Unduplicated) 819 2917.750000 107634.2500 36.8895
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Screening, Eval, and Assessment,Class #02
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
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 10.000000 600.0000 60.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 6.000000 300.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 10.000000 555.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 52.000000 3900.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 96 203.000000 14486.0000 71.3596
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 52.000000 3900.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 64 141.500000 9562.5000 67.5795
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 27 58.000000 3860.0000 66.5517
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 45.500000 2525.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 87 171.500000 9573.7500 55.8236
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.0500 51.0250
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 33 34.000000 1650.0000 48.5294
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 3 3.000000 153.1500 51.0500
SPCH-92610TLGT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUN 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 210 876.000000 57146.5500 65.2358
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 19 17.750000 887.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 83 106.500000 5325.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 83 89.500000 2237.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 44 60.000000 3000.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 87 158.500000 7925.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 11 5.750000 143.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 28 23.500000 1175.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 62 92.750000 4637.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 2.500000 62.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 11.000000 550.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 28 30.000000 1500.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 3.500000 87.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 18 20.000000 1000.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 46 66.250000 3312.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 10 6.250000 156.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 29 34.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 176 498.250000 24912.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 197 692.500000 34625.0000 50.0000
INTR-T1013-INTERPRETER 5 35.000000 1750.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 335 1022.000000 10220.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 31.000000 1857.4400 59.9174
OCCT-97530GT-OT SESSION BY LICENSED OT 24 89.250000 6161.7000 69.0387
OCCT-97530HM-OT SESSION BY OT ASST 7 12.000000 686.4000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 7 31.750000 1816.1000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 21 41.750000 2911.1800 69.7289
OCCT-97530TLGT-OT SESSION BY LICENSED OT 27 100.250000 7161.8600 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 8 28.000000 1601.6000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 3 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 20 46.500000 2839.7400 61.0697
PHY-97110GT-PT SESSION BY LICENSED PT 23 93.500000 5858.0800 62.6533
PHY-97110TL-PT SESSION BY LICENSED PT 25 61.500000 4393.5600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 19 75.250000 5375.8600 71.4400
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 1000.0000 500.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 71 168.750000 11912.6200 70.5933
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 98 553.250000 37143.7800 67.1374
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 41 112.250000 8019.1400 71.4400
CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 Page: 2
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 43 177.750000 12698.4600 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 16 19.250000 712.2500 37.0000
TRAV-TRAVS-Travel by mile 280 11035.00000 4909.5600 0.4449
Subtotal (Total Children Is Unduplicated) 560 15661.00000 220831.6300 14.1007
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Total 19454.750000 385612.4300 19.8210
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Number of Children (Unduplicated) With at Least One Service 867
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Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 6.000000 450.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1373 1417.500000 63314.7000 0.0000
P 302 292.500000 11893.5900 11801.9100
D 0 0.000000 0.0000 0.0000
S 337 367.000000 14432.5000 46.7500
H 50 59.750000 4105.0200 0.0000
T 2554 13872.250000 116431.6700 109389.4500
3158 3439.750000 174984.9500 92.5000
Other 0 0.000000 0.0000 0.0000
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Total 7777 19454.750000 385612.4300 121330.6100