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:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 728 1872.000000 69125.2500 36.9259
Subtotal (Total Children Is Unduplicated) 728 1872.000000 69125.2500 36.9259
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 13.8700 13.8700
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 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 9 16.000000 1200.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 31.500000 1748.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 50.500000 3712.5000 73.5149
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 41.000000 3075.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 28.500000 2137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 107 176.500000 9740.2500 55.1856
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 104 182.000000 13575.0000 74.5879
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 187 554.500000 37192.7000 67.0743
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 15.000000 1099.8000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 13 23.000000 575.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 465 2118.750000 105848.5000 49.9580
OCCT-97530-OT SESSION BY LICENSED OT 39 160.500000 11281.0000 70.2866
OCCT-97530HM-OT SESSION BY OT ASST 4 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 44 167.000000 11859.0800 71.0125
PHY-97110HM-PT SESSION BY PT ASST 11 21.000000 1200.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 111.750000 7744.2400 69.2997
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 41.6400 13.8800
Subtotal (Total Children Is Unduplicated) 528 2625.000000 139935.6200 53.3088
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Total 5051.500000 246253.5700 48.7486
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Number of Children (Unduplicated) With at Least One Service 943
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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 1809 1679.750000 77186.8700 75841.6300
D 22 16.250000 857.2700 0.0000
S 63 53.750000 1942.5000 1850.0000
H 2 1.500000 107.1600 0.0000
T 0 0.000000 0.0000 0.0000
1975 2006.250000 105879.9000 0.0000
Other 4 2.750000 170.6300 0.0000
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Total 5226 5051.500000 246253.5700 77810.1300