CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2018 ending 09/30/2018 Date of Report:11/06/2018 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 876 1058.250000 39090.5000 36.9388
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 577 753.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 952 2559.500000 94572.0000 36.9494
Subtotal (Total Children Is Unduplicated) 1141 4371.000000 133662.5000 30.5794
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 37.8300 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 42.1200 8.4240
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 4 4.000000 37.1400 9.2850
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 179.6900 25.6700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.000000 92.7500 18.5500
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 44.500000 3337.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 28 65.000000 4875.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 35.000000 2625.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 57.000000 3163.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 60.500000 4537.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 32.000000 2400.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 35.000000 2625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 192 328.000000 18148.5000 55.3308
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 191 333.000000 24975.0000 75.0000
Subtotal (Total Children Is Unduplicated) 305 1019.500000 67437.5300 66.1477
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 116.4000 116.4000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 35 31.250000 1537.5000 49.2000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 2.250000 56.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 310 573.250000 28625.0000 49.9346
CONIP-CONIP-CONSULT, ITDS PHONE 24 9.000000 225.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 157 98.250000 4900.0000 49.8728
CONOP-CONOP-CONSULT, OT, PHONE 15 6.250000 156.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 167 105.000000 5250.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 117 68.750000 3437.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 11 19.000000 1393.0800 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 616 1996.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 15 18.250000 456.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 693 3882.250000 194137.5000 50.0064
INTR-T1013-INTERPRETER 1 8.000000 560.0000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 888 6729.000000 67280.0000 9.9985
OCCT-97530-OT SESSION BY LICENSED OT 21 124.999996 8929.9996 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 51.000000 3643.4400 71.4400
TRAV-TRAVS-Travel by mile 499 41440.00000 18445.8500 0.4451
Subtotal (Total Children Is Unduplicated) 889 55167.25000 339225.0196 6.1490
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Total 60557.749996 540325.0496 8.9225
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Number of Children (Unduplicated) With at Least One Service 1263
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Center 53
Flag Claims Units Chgs Paid
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R 160 157.000000 7242.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1075 1019.000000 45841.7500 0.0000
P 2523 2424.694200 111948.7100 110866.4800
D 41 44.000000 2465.1000 0.0000
S 1 0.500000 18.5000 0.0000
H 1793 12545.250000 22372.4100 22172.4100
T 2461 18259.000000 31489.3000 31489.3000
16013 25822.305796 303054.0296 0.0000
Other 254 286.000000 15892.7500 0.0000
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Total 24321 60557.749996 540325.0496 164528.1900