CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 ending 06/30/2021 Date of Report:07/15/2021 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
CASE-CASE-NON-TCM CASE MANAGEMENT 2514 6828.250000 252406.2500 36.9650
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 63 77.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3041 14497.25000 535845.2500 36.9619
Subtotal (Total Children Is Unduplicated) 3087 21402.75000 788251.5000 36.8294
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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 9 9.000000 177.3900 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 83.2200 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 9.000000 81.7200 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 18 18.000000 500.9400 27.8300
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 38.4700 38.4700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 33.4000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.000000 67.2000 22.4000
EVAL-96111-DEVELOPMENTAL EVALUATION 8 14.000000 700.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 57 105.500000 5275.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 29 54.500000 4087.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 34 62.000000 4650.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 27 51.000000 3825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 17 32.500000 2437.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 16.000000 888.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 59 115.000000 6327.0000 55.0174
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 55.500000 4162.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 402 749.500000 56212.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 47 80.000000 6000.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 405 742.500090 55948.5067 75.3515
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 278 500.000000 37500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 15.500000 860.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 817 1641.000000 91238.7500 55.5995
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 337 625.500000 46912.5000 75.0000
SCREEN-T1023-SCREENING 2 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1140 4953.000090 331152.8367 66.8590
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 293.3800 293.3800
AUDE-V5160-DISPENSING FEE BINAURAL 3 3.000000 690.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 24 17.000000 850.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 82 68.500000 3425.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 2.000000 50.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 60 29.000000 1450.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 629 990.750000 49477.0000 49.9389
CONIP-CONIP-CONSULT, ITDS PHONE 3 4.000000 93.7500 23.4375
CONOF-CONOF-CONSULT, OT, FACE TO FACE 45 30.250000 1512.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 533 577.000000 27625.0000 47.8769
CONOP-CONOP-CONSULT, OT, PHONE 12 9.750000 243.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 47 30.000000 1500.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 406 304.750000 15237.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 75 58.500000 2900.0000 49.5726
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 479 526.500000 26312.5000 49.9763
CONSP-CONSP-CONSULT, SLP, PHONE 11 8.000000 200.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 68 168.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 8.500000 212.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 111 337.750000 16887.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 903 9864.000000 493200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 81 204.000000 2040.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 24 43.000000 3071.9200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 93 759.750000 54875.0200 72.2277
OCCT-97530TL-OT SESSION BY LICENSED OT 5 11.000000 785.8400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 90 683.250000 48811.3800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 16 48.750000 3563.2600 73.0925
PHY-97110GT-PT SESSION BY LICENSED PT 60 656.250034 48998.2622 74.6640
PHY-97110TL-PT SESSION BY LICENSED PT 3 9.000000 642.9600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 55 539.250000 38524.0200 71.4400
SENS-V5264-EARMOLD 2 5.000000 90.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 46.000000 3286.2400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 81 618.250000 44149.4100 71.4103
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 9 25.000000 1786.0000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 103 898.500000 64109.8400 71.3521
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 128 208.750000 7723.7500 37.0000
TRAV-TRAVS-Travel by mile 15 773.000000 343.9500 0.4450
CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 ending 06/30/2021 Date of Report:07/15/2021 Page: 2
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Subtotal (Total Children Is Unduplicated) 1314 18569.25003 965001.1122 51.9677
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Total 44925.000124 2084405.4489 46.3975
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Number of Children (Unduplicated) With at Least One Service 3115
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Center 53
Flag Claims Units Chgs Paid
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R 2556 2350.000000 112204.8400 0.0000
U 0 0.000000 0.0000 0.0000
B 3581 3218.000000 154932.2100 59.2500
P 14573 13156.160100 628894.9355 626374.8100
D 625 572.590000 34182.7600 0.0000
S 263 244.750000 14558.2700 0.0000
H 28 28.000000 1964.6000 0.0000
T 1427 1705.789436 74076.2075 73830.4600
32886 23021.210588 1022221.2159 83.2500
Other 586 628.500000 41370.4100 238.5000
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Total 56525 44925.000124 2084405.4489 700586.2700