CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2017 ending 06/30/2018 Date of Report:08/10/2018 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 2078 4617.000000 170672.7500 36.9662
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1894 4288.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 792 3255.750000 120333.2500 36.9602
Subtotal (Total Children Is Unduplicated) 2460 12161.50000 291006.0000 23.9285
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 7.000000 339.5000 48.5000
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 51.3500 51.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 37.8300 12.6100
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 21.5500 21.5500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 10.000000 82.6000 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 6 6.000000 54.3600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 9 9.000000 227.7900 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 74.2000 18.5500
EXIT-EXIT-EXIT ASSESSMENT 28 27.500000 1375.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 25.000000 1875.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 35 39.500000 2962.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 8.990223 674.2667 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 35 41.500000 2303.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 26.500000 1987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 20.500000 1537.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 18.000000 1350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 108 183.297297 10173.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 75 133.000000 9975.0000 75.0000
Subtotal (Total Children Is Unduplicated) 247 566.787520 35252.1967 62.1965
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 10.000000 1101.4500 110.1450
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 201 228.250000 11412.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 13 8.750000 218.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 758 3372.250000 168468.7500 49.9574
CONIP-CONIP-CONSULT, ITDS PHONE 121 63.500000 1587.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 3.250000 162.5000 50.0000
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
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.250000 31.2500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 19 54.000000 3959.2800 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1204 6333.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 14 29.750000 743.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 245 1559.896800 77981.8400 49.9917
INTR-T1013-INTERPRETER 4 21.250000 1287.5000 60.5882
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1650 26945.00000 269401.0000 9.9982
OCCT-97530-OT SESSION BY LICENSED OT 10 64.536813 4610.5100 71.4400
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 60.000000 4286.4000 71.4400
TRAV-TRAVS-Travel by mile 1082 205202.0000 91338.3300 0.4451
Subtotal (Total Children Is Unduplicated) 1654 243961.6836 636796.8100 2.6102
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Total 256689.971133 963055.0067 3.7518
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Number of Children (Unduplicated) With at Least One Service 2499
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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 7 5.750000 212.7500 0.0000
D 1 1.000000 71.4400 0.0000
S 19 17.750000 656.7500 0.0000
H 15976 123012.601483 193209.1200 193209.1200
T 9101 69673.287520 117118.9267 117108.9300
49100 63969.582130 651236.0200 50.0000
Other 9 10.000000 550.0000 0.0000
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Total 74213 256689.971133 963055.0067 310368.0500