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: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 1 0.750000 27.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 28 62.000000 2294.0000 37.0000
Subtotal (Total Children Is Unduplicated) 29 62.750000 2321.7500 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 3 4.000000 300.0000 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 5 8.500000 637.5000 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 8 12.500000 693.7500 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 38 65.500000 4912.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 19.500000 1462.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 32 49.500000 3712.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 13 21.500000 1612.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 28.000000 2100.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 125 203.000000 11265.5000 55.4951
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 42 72.500000 3968.2500 54.7345
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 84 150.500000 11287.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 32.000000 2400.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 249 732.500000 47100.9300 64.3016
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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 4172.640000 251243.2860 60.2121
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Number of Children (Unduplicated) With at Least One Service 405
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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 83 57.000000 2109.0000 0.0000
P 151 131.610000 9014.4000 12247.6400
D 761 783.270000 46587.7960 0.0000
S 10 9.250000 652.2100 0.0000
H 0 0.000000 0.0000 0.0000
T 581 578.534306 30238.2100 29988.2100
2069 2237.725694 137646.2200 0.0000
Other 357 375.250000 24995.4500 0.0000
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Total 4012 4172.640000 251243.2860 42235.8500