CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2019 ending 03/31/2019 Date of Report:05/04/2019 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 851 1265.750000 46795.7500 36.9708
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 610 673.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1025 2726.000000 100722.7500 36.9489
Subtotal (Total Children Is Unduplicated) 1168 4665.500000 147518.5000 31.6190
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.7100 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 27.7400 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 27.2400 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 139.1500 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 33.4000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 5 6.500000 325.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 24.000000 1800.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 22.000000 1650.0000 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 10 18.000000 1350.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 44.000000 2433.7500 55.3125
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 56 91.000000 6750.0000 74.1758
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 51.000000 3825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 43.500000 3262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 178 300.999999 16622.2500 55.2234
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 155 275.500000 20587.5000 74.7278
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 286 892.999999 59025.7000 66.0982
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 331.9200 331.9200
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 36 30.000000 1500.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 8 3.750000 93.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 250 468.500000 23418.7500 49.9867
CONIP-CONIP-CONSULT, ITDS PHONE 21 9.750000 243.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 111 63.000000 3137.5000 49.8016
CONOP-CONOP-CONSULT, OT, PHONE 29 17.750000 443.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 173 131.500000 6425.0000 48.8593
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 177 136.000000 6800.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 12 3.500000 87.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 11 26.000000 1906.3200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 631 1845.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 18 34.000000 850.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 606 2816.750000 140748.5000 49.9684
INTR-T1013-INTERPRETER 1 2.000000 70.0000 35.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 905 5846.000000 58420.0000 9.9932
OCCT-97530-OT SESSION BY LICENSED OT 59 297.500000 20897.4000 70.2434
OCCT-97530HM-OT SESSION BY OT ASST 5 6.000000 343.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 58 273.000000 19435.3000 71.1916
PHY-97110HM-PT SESSION BY PT ASST 14 28.000000 1600.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 58 237.250000 16602.7600 69.9800
SPL-92508-GROUP SPL SESSION PER CHILD 7 11.000000 152.6800 13.8800
TRAV-TRAVS-Travel by mile 492 41985.00000 18680.4100 0.4449
Subtotal (Total Children Is Unduplicated) 907 54273.25000 322238.9700 5.9373
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Total 59831.749999 528783.1700 8.8378
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Number of Children (Unduplicated) With at Least One Service 1340
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Center 53
Flag Claims Units Chgs Paid
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R 7 8.250000 381.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1344 1283.000000 59727.9900 118.5000
P 1832 1703.778672 78538.6100 77898.8600
D 53 54.835585 2841.5200 0.0000
S 63 53.750000 1942.5000 1850.0000
H 668 4174.500000 8629.4300 8522.2700
T 1869 13889.000000 24120.7100 24120.7100
16900 38610.635742 349479.5100 0.0000
Other 47 54.000000 3121.6500 0.0000
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Total 22783 59831.749999 528783.1700 112510.3400