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
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 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 45 130.250000 4819.2500 37.0000
Subtotal (Total Children Is Unduplicated) 46 130.750000 4837.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
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 5 5.000000 98.5500 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 27.7400 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 5.000000 45.4000 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 10 10.000000 278.3000 27.8300
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 38.4700 38.4700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 22.4000 22.4000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 21.500000 1193.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.500000 862.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 83 155.000000 11625.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 16.500000 1237.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 101 185.500090 14212.5067 76.6172
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 50 92.500000 6937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 148 275.500000 15546.0000 56.4283
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 58 109.000000 8175.0000 75.0000
Subtotal (Total Children Is Unduplicated) 259 941.000090 63760.8167 67.7586
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AUDE-V5160-DISPENSING FEE BINAURAL 3 3.000000 690.0000 230.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 2.000000 100.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 62.250000 3112.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 137 1251.750000 62587.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 17.000000 1214.4800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 50 469.750000 34157.4200 72.7140
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 7.000000 500.0800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 30.750000 2277.3400 74.0598
PHY-97110GT-PT SESSION BY LICENSED PT 31 445.000034 33906.5622 76.1945
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.750000 53.5800 71.4400
SENS-V5264-EARMOLD 2 5.000000 90.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 23.000000 1643.1200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 61 506.750000 36219.5700 71.4742
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 285.7600 71.4400
Subtotal (Total Children Is Unduplicated) 270 2830.000034 176887.9122 62.5046
-----------------------------------------------------------------------------------------------------------------------
Total 3901.750124 245486.4789 62.9170
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 402
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 40 42.000000 1554.0000 0.0000
P 60 51.660000 7091.5100 5805.5600
D 228 221.340000 14754.6600 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 500 508.539436 27998.9675 27998.9700
2147 2480.960688 154393.1014 83.2500
Other 553 597.250000 39694.2400 0.0000
---------------------------------------------------------
Total 3528 3901.750124 245486.4789 33887.7800