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
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 890 1202.000000 44474.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 635 738.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 294 817.000000 30173.5000 36.9321
Subtotal (Total Children Is Unduplicated) 1072 2757.250000 74647.5000 27.0732
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Screening, Eval, and Assessment,Class #02
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 11 13.500000 1012.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 9.000000 675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 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 9 15.500000 860.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 19.000000 1054.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 20.000000 1500.0000 75.0000
Subtotal (Total Children Is Unduplicated) 45 97.750000 6098.6100 62.3899
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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 9 18.000000 1319.7600 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 661 1928.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 9.000000 225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 56 188.000000 9400.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 140.0000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 947 6594.000000 65920.0000 9.9970
OCCT-97530-OT SESSION BY LICENSED OT 1 0.750000 53.5800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 9.000000 642.9600 71.4400
TRAV-TRAVS-Travel by mile 552 45899.00000 20430.6900 0.4451
Subtotal (Total Children Is Unduplicated) 948 55485.25000 139494.1700 2.5141
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Total 58340.250000 220240.2800 3.7751
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Number of Children (Unduplicated) With at Least One Service 1252
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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 1 1.000000 73.3200 0.0000
S 0 0.000000 0.0000 0.0000
H 2202 15702.500000 24922.6000 24922.6000
T 3431 29029.000000 38586.5300 38586.5300
12375 13607.750000 156657.8300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18009 58340.250000 220240.2800 63509.1300