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
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 876 1058.250000 39090.5000 36.9388
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 577 752.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 311 780.750000 28832.2500 36.9289
Subtotal (Total Children Is Unduplicated) 1060 2591.500000 67922.7500 26.2098
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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) 2 2.000000 25.2200 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 33.8600 8.4650
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 28.0800 9.3600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 154.3800 25.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 74.2000 18.5500
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 13.000000 975.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 39.500000 2192.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 32.000000 2400.0000 75.0000
Subtotal (Total Children Is Unduplicated) 63 149.500000 9018.2400 60.3227
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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 17.000000 1246.4400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 616 1996.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 65 297.894200 14894.7100 50.0000
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 4 9.270436 662.2800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 36.000000 2571.8400 71.4400
TRAV-TRAVS-Travel by mile 499 41440.00000 18445.8500 0.4451
Subtotal (Total Children Is Unduplicated) 889 51434.91464 150115.0200 2.9185
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Total 54175.914636 227056.0100 4.1911
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Number of Children (Unduplicated) With at Least One Service 1229
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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 5 5.000000 366.6000 0.0000
S 0 0.000000 0.0000 0.0000
H 1783 12532.750000 21786.1200 21586.1200
T 2459 18256.000000 31328.3000 31328.3000
13826 23382.164636 173574.9900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18073 54175.914636 227056.0100 52914.4200