CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 890 1202.000000 44474.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 635 738.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1013 2856.000000 105441.2500 36.9192
Subtotal (Total Children Is Unduplicated) 1174 4796.250000 149915.2500 31.2568
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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) 1 1.000000 13.8700 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.1600 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 8 8.250000 412.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 49.500000 3712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 30 62.500000 4687.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 17.000000 1275.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 36 78.000000 4356.7500 55.8558
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 77.000000 5775.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 58.500000 4387.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 34.500000 2587.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 221 373.000000 20590.5000 55.2024
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 174 296.500000 22200.0000 74.8735
Subtotal (Total Children Is Unduplicated) 334 1065.250000 70392.1100 66.0804
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 49.4300 49.4300
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 28 21.750000 1087.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 277 543.000000 27150.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 23 7.500000 181.5000 24.2000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 167 104.250000 5200.0000 49.8801
CONOP-CONOP-CONSULT, OT, PHONE 18 7.250000 181.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 144 94.000000 4687.5000 49.8670
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 81 54.500000 2725.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 7 2.000000 50.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 22.000000 1613.0400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 661 1928.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 25 39.000000 975.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 766 4115.000000 205750.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 140.0000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 947 6595.000000 65930.0000 9.9970
OCCT-97530-OT SESSION BY LICENSED OT 16 54.499992 3893.4792 71.4400
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 24.000000 1714.5600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 552 45905.00000 20433.3700 0.4451
Subtotal (Total Children Is Unduplicated) 948 59524.99999 341861.5092 5.7432
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Total 65386.499992 562168.8692 8.5976
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Number of Children (Unduplicated) With at Least One Service 1290
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Center 53
Flag Claims Units Chgs Paid
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R 21 18.500000 739.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 837 789.000000 32932.5000 29.7500
P 2902 2956.320600 138660.0300 138767.1700
D 1 1.000000 73.3200 0.0000
S 19 19.250000 776.0000 0.0000
H 2270 15766.537512 28416.4600 28416.4600
T 3475 29076.000000 41165.4900 41165.4900
15160 16495.391880 304341.5992 0.0000
Other 224 264.500000 15063.9700 0.0000
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Total 24909 65386.499992 562168.8692 208378.8700