CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 Page: 1
List order: No List
Payclass Filters:GR
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 771 1016.750000 37610.5000 36.9909
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 652 742.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 335 903.250000 33420.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1010 2662.000000 71030.7500 26.6832
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 25.2200 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 8.2600 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 25.3100 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 37.1000 18.5500
EXIT-EXIT-EXIT ASSESSMENT 9 9.000000 450.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 11.000000 825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 38.000000 2109.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 27.500000 2062.5000 75.0000
Subtotal (Total Children Is Unduplicated) 55 123.000000 7751.2000 63.0179
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 41 39.000000 1950.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 2.000000 50.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 294 863.000000 43106.2500 49.9493
CONIP-CONIP-CONSULT, ITDS PHONE 47 23.250000 581.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 0.500000 25.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 0.500000 12.5000 25.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.750000 18.7500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 2.000000 146.6400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 556 1716.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 66 226.121400 11306.0700 50.0000
INTR-T1013-INTERPRETER 1 4.000000 140.0000 35.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 805 6199.000000 61980.0000 9.9984
OCCT-97530-OT SESSION BY LICENSED OT 4 19.000000 1357.3600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 25.000000 1786.0000 71.4400
TRAV-TRAVS-Travel by mile 479 43818.00000 19504.3200 0.4451
Subtotal (Total Children Is Unduplicated) 811 52942.12140 142064.1400 2.6834
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Total 55727.121400 220846.0900 3.9630
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Number of Children (Unduplicated) With at Least One Service 1161
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3965 29257.500000 47060.7000 47060.7000
T 2070 15712.250000 27144.5800 27144.5800
11373 10757.371400 146640.8100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 17408 55727.121400 220846.0900 74205.2800