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
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 850 1263.000000 46694.0000 36.9707
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 609 671.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 297 825.750000 30552.2500 36.9994
Subtotal (Total Children Is Unduplicated) 1041 2760.000000 77246.2500 27.9878
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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-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 4 5.500000 275.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 22.000000 1221.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 25.500000 1912.5000 75.0000
Subtotal (Total Children Is Unduplicated) 35 78.500000 5140.7400 65.4871
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 331.9200 331.9200
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 177 135.000000 6750.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 12 3.500000 87.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 9.000000 659.8800 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 631 1843.500000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 50 190.500000 9525.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 70.0000 35.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 905 5845.000000 58410.0000 9.9932
OCCT-97530-OT SESSION BY LICENSED OT 5 21.000000 1500.2400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 26.000000 1814.5600 69.7908
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 27.7600 13.8800
TRAV-TRAVS-Travel by mile 492 41985.00000 18680.4100 0.4449
Subtotal (Total Children Is Unduplicated) 907 50793.75000 133269.7700 2.6237
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Total 53632.250000 215656.7600 4.0210
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Number of Children (Unduplicated) With at Least One Service 1266
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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 1 1.000000 50.0000 50.0000
D 10 15.500000 725.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 659 4165.500000 8092.5800 8092.5800
T 1837 13857.000000 21968.6500 21968.6500
13994 35593.250000 184820.0300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16501 53632.250000 215656.7600 30111.2300