CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 2860 9497.500000 351065.2500 36.9640
Subtotal (Total Children Is Unduplicated) 2860 9497.500000 351065.2500 36.9640
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 9 9.000000 175.6900 19.5211
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 9 9.000000 128.3800 14.2644
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.7000 23.7000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 9 9.000000 85.2700 9.4744
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 9 10.000000 292.9600 29.2960
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 7 7.000000 150.7600 21.5371
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 14 26.000000 1950.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.500000 187.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.500000 487.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 16.500000 915.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 59 121.000000 9075.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 351 686.500000 51487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 30.500000 2287.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 127 252.500000 18937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 30.500000 2287.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 75 137.000000 10275.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 132.000000 7326.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 281 541.000000 30025.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 34.000000 2511.0000 73.8529
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 93 194.000000 14550.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 8 8.000000 408.4000 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 10 10.000000 510.5000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 18 18.000000 918.9000 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 5.000000 204.2000 40.8400
Subtotal (Total Children Is Unduplicated) 605 2339.500000 157750.2600 67.4290
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 31.000000 8822.3400 284.5916
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 33 36.500000 1825.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 179 179.500000 8975.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 36 31.000000 775.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 62 88.500000 4425.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 171 241.250000 12062.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 10 10.750000 268.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 27 41.000000 2050.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 7 7.000000 350.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 75 94.250000 4712.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 17 20.000000 1000.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 157 186.000000 9300.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 534 4579.500000 228926.0000 49.9893
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 770 5430.500000 271525.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 725 7648.000000 76480.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 248 1100.000000 76313.1600 69.3756
OCCT-97530GT-OT SESSION BY LICENSED OT 75 343.750000 24418.8000 71.0365
OCCT-97530HM-OT SESSION BY OT ASST 36 191.000000 10526.5200 55.1127
OCCT-97530HMGT-OT SESSION BY OT ASST 4 18.750000 1072.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 347 1650.500000 116889.5300 70.8207
PHY-97110GT-PT SESSION BY LICENSED PT 104 361.500000 25137.5000 69.5367
SENS-V5264-EARMOLD 3 7.000000 126.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 368 1724.750000 121972.0900 70.7187
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 200 1043.750000 74309.0000 71.1943
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 2.000000 114.4000 57.2000
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 3.500000 250.0400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.500000 34.7000 13.8800
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 31 41.000000 1517.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1728 25123.75000 1084503.3300 43.1665
-----------------------------------------------------------------------------------------------------------------------
Total 36960.750000 1593318.8400 43.1084
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3172
-----------------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 305 227.750000 8898.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1525 1207.750000 47606.5000 0.0000
P 12392 20178.250000 705092.9400 706839.5300
D 90 112.000000 6993.7500 0.0000
S 171 289.000000 16967.2600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8164 14946.000000 807759.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22647 36960.750000 1593318.8400 706839.5300