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:TPIN
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 1 2.750000 101.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 2.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 13 28.250000 1045.2500 37.0000
Subtotal (Total Children Is Unduplicated) 13 33.500000 1147.0000 34.2388
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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) 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 3 3.000000 83.4900 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 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 5 9.500000 519.0000 54.6316
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 35.500000 2662.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 14.000000 1050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 58 102.499999 5661.0000 55.2293
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 68.000000 5100.0000 75.0000
Subtotal (Total Children Is Unduplicated) 82 257.999999 16581.2600 64.2685
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 2.000000 146.6400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 1.500000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 5.000000 125.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 113 493.500000 24675.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 116.000000 8116.1600 69.9669
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 14 106.000000 7576.2200 71.4738
PHY-97110HM-PT SESSION BY PT ASST 3 7.000000 400.1200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 97.500000 6901.0800 70.7803
SPL-92508-GROUP SPL SESSION PER CHILD 5 6.000000 83.2800 13.8800
Subtotal (Total Children Is Unduplicated) 153 838.500000 48190.7000 57.4725
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Total 1129.999999 65918.9600 58.3354
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Number of Children (Unduplicated) With at Least One Service 199
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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 22 23.028672 1301.7400 2007.2300
D 21 23.085585 1258.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 7 7.500000 429.6900 429.6900
T 32 32.000000 2152.0600 2152.0600
914 993.135742 57825.7000 0.0000
Other 43 51.250000 2951.0200 0.0000
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Total 1039 1129.999999 65918.9600 4588.9800