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
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 2488 6764.500000 250138.5000 36.9781
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1609 2398.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2735 12541.25000 463498.5000 36.9579
Subtotal (Total Children Is Unduplicated) 2890 21704.50000 713637.0000 32.8797
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 5.000000 98.5500 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.000000 46.9800 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 8.000000 110.9600 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 13 13.000000 118.0400 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 6 6.000000 59.7600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 14 16.000000 445.2800 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) 10 10.000000 167.0000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 44.8000 22.4000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 4 5.000000 250.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 18 21.750000 1087.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 29.500000 2212.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 20.500000 1537.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 19 29.000000 2175.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 27 47.000000 3487.5000 74.2021
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 15.500000 1162.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 58 96.500000 5355.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 129 224.500000 16762.5000 74.6659
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 53 96.500000 7237.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 163 266.000000 19950.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 51 91.000000 6825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 137 223.500000 16762.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 29 50.000000 3750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 627 1073.000000 59467.2500 55.4215
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 169 300.000000 16539.0000 55.1300
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 436 783.000000 58687.5000 74.9521
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 92 170.000000 12750.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 7 13.000000 650.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 1118 3654.250000 240057.7200 65.6927
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 5.000000 245.6600 49.1320
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 76 65.000000 3250.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 12 11.500000 575.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 25 19.500000 487.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 582 1333.000000 66612.5000 49.9719
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 284 391.000000 19550.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 44 23.750000 593.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 446 427.750000 21387.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 237 190.000000 9500.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 76 39.750000 993.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 399 362.500000 18125.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 174 107.750000 5387.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 4.500000 112.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 410 377.750000 18862.5000 49.9338
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 234 224.750000 11225.0000 49.9444
CONSP-CONSP-CONSULT, SLP, PHONE 34 18.750000 468.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1193 5630.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 52 175.000000 4375.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 897 9339.500000 466870.0000 49.9888
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 427 2121.750000 106087.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1481 17331.00000 173290.0000 9.9988
OCCT-97530-OT SESSION BY LICENSED OT 109 968.500000 69163.9600 71.4135
OCCT-97530GT-OT SESSION BY LICENSED OT 55 223.250000 15948.9800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 3.000000 171.6000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 3 12.000000 857.2800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 39 131.500000 9394.3600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 112 1154.210000 82281.0200 71.2877
PHY-97110GT-PT SESSION BY LICENSED PT 46 205.840000 14741.7600 71.6176
PHY-97110TL-PT SESSION BY LICENSED PT 9 16.250000 1160.9000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 31 155.500000 11048.0800 71.0487
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 122 1026.800000 71827.6060 69.9529
CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2019 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-92507GT-SPL THERAPY SESSION BY LICENSED SLP 58 232.250000 16591.9400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 7 18.000000 1285.9200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 35 128.000000 9144.3200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 6 5.000000 69.4000 13.8800
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 2.500000 34.7000 13.8800
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 97 196.750000 7279.7500 37.0000
TRAV-TRAVS-Travel by mile 938 138385.0000 61562.5700 0.4449
Subtotal (Total Children Is Unduplicated) 1600 181065.6000 1300613.5560 7.1831
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Total 206424.350000 2254308.2760 10.9207
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Number of Children (Unduplicated) With at Least One Service 2910
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Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 39 30.500000 1548.0900 0.0000
U 0 0.000000 0.0000 0.0000
B 3701 3214.250000 153777.9000 149.1900
P 12702 11685.570000 542362.1700 546871.2800
D 1610 1572.020000 90038.0560 0.0000
S 20 161.750000 755.5100 0.0000
H 43 42.500000 2827.1600 50.0000
T 20145 148800.034306 279191.1800 278271.6800
51312 40333.225694 1144507.9500 37.0000
Other 572 584.500000 39300.2600 0.0000
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Total 90144 206424.350000 2254308.2760 825379.1500