CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2019 ending 06/30/2020 Date of Report:07/21/2020 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.750000 27.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 59.250000 2192.2500 37.0000
Subtotal (Total Children Is Unduplicated) 27 60.000000 2220.0000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.000000 78.8400 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.000000 46.9800 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.000000 69.3500 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 7.000000 63.5600 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 29.8800 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 9.000000 250.4700 27.8300
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 38.4700 38.4700
AUDE-92585-AUD EVOKED RESPONSE (COMP) 2 2.000000 169.6800 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.000000 83.5000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 22.4000 22.4000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 50.500000 3787.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 17.500000 1312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 26.500000 1987.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 12.500000 937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 20.500000 1537.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 84 142.000000 7880.0000 55.4930
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 32 57.000000 3108.0000 54.5263
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 63 112.500000 8437.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 24.500000 1837.5000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 180 545.500000 34626.1800 63.4760
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 145 1449.790000 72460.2000 49.9798
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 64 296.500000 14825.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 39 369.750000 26403.5000 71.4091
OCCT-97530GT-OT SESSION BY LICENSED OT 23 110.500000 7894.1200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 36 364.460000 26017.5200 71.3865
PHY-97110GT-PT SESSION BY LICENSED PT 23 147.840000 10598.2400 71.6872
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 457.800000 31235.8060 68.2302
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 32 167.750000 11984.0600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 288 3377.390000 201820.6060 59.7564
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Total 3982.890000 238666.7860 59.9230
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Number of Children (Unduplicated) With at Least One Service 336
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Center 53
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 80 54.250000 2007.2500 0.0000
P 148 127.690000 8766.9000 11977.6400
D 744 762.190000 45223.5460 0.0000
S 10 9.250000 652.2100 0.0000
H 0 0.000000 0.0000 0.0000
T 579 575.034306 29975.7100 29725.7100
1980 2097.725694 128335.7200 0.0000
Other 343 356.750000 23705.4500 0.0000
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Total 3884 3982.890000 238666.7860 41703.3500