CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2019 ending 06/30/2019 Date of Report:07/21/2019 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 1026 1633.000000 60356.2500 36.9603
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 706 771.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1166 2978.750000 109927.0000 36.9037
Subtotal (Total Children Is Unduplicated) 1324 5382.750000 170283.2500 31.6350
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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) 1 1.000000 13.8700 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 55.6600 27.8300
EXIT-EXIT-EXIT ASSESSMENT 8 7.500000 375.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 15.500000 1162.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 30.000000 1665.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 60 100.500000 7537.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 62.000000 4650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 42 64.500000 4800.0000 74.4186
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 214 348.500000 19226.2500 55.1686
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 160 275.500000 20587.5000 74.7278
SCREEN-T1023-SCREENING 5 7.000000 350.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 315 949.500000 62940.6200 66.2882
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.000000 2195.9000 731.9667
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 39 33.000000 1613.2500 48.8864
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 5 1.250000 31.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 269 481.500000 24050.0000 49.9481
CONIP-CONIP-CONSULT, ITDS PHONE 23 8.250000 206.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 122 91.500000 4550.0000 49.7268
CONOP-CONOP-CONSULT, OT, PHONE 4 1.250000 31.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 136 85.500000 4275.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 145 99.000000 4950.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 11 6.000000 150.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 647 1935.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 23 42.000000 1050.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 589 3325.000000 166250.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 929 6541.000000 65400.0000 9.9985
OCCT-97530-OT SESSION BY LICENSED OT 71 300.250000 21335.6200 71.0595
OCCT-97530HM-OT SESSION BY OT ASST 12 31.000000 1773.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 74 425.250000 30365.5800 71.4064
PHY-97110HM-PT SESSION BY PT ASST 4 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 73 385.250000 27461.1200 71.2813
SPL-92508-GROUP SPL SESSION PER CHILD 4 4.250000 58.9900 13.8800
TRAV-TRAVS-Travel by mile 556 45953.00000 20442.5700 0.4449
Subtotal (Total Children Is Unduplicated) 941 59756.25000 376418.6200 6.2992
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Total 66088.500000 609642.4900 9.2246
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Number of Children (Unduplicated) With at Least One Service 1436
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Center 53
Flag Claims Units Chgs Paid
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R 9 8.250000 378.9300 0.0000
U 0 0.000000 0.0000 0.0000
B 2923 2692.750000 127123.0900 18.5000
P 1192 1134.250000 54141.8500 54029.8000
D 45 41.750000 2386.4000 0.0000
S 46 47.000000 1937.9600 1652.2000
H 4025 27669.500000 52853.1700 51734.8900
T 9 5.250000 85.5000 76.2500
17730 34080.000000 344372.9900 0.0000
Other 372 409.750000 26362.6000 0.0000
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Total 26351 66088.500000 609642.4900 107511.6400