CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2019 ending 06/30/2019 Date of Report:07/22/2019 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 1026 1633.000000 60356.2500 36.9603
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 706 771.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 309 800.750000 29563.0000 36.9191
Subtotal (Total Children Is Unduplicated) 1202 3204.750000 89919.2500 28.0581
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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) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
EXIT-EXIT-EXIT ASSESSMENT 8 7.500000 375.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.000000 75.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.000000 825.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 23.000000 1276.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 21.500000 1612.5000 75.0000
SCREEN-T1023-SCREENING 4 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 37 77.500000 4877.2800 62.9326
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EI Services,Class #03
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 6 13.750000 343.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 44 278.250000 13912.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 929 6540.000000 65390.0000 9.9985
OCCT-97530-OT SESSION BY LICENSED OT 6 33.000000 2357.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 16.000000 1143.0400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 20.000000 1407.3600 70.3680
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 556 45925.00000 20430.1100 0.4449
Subtotal (Total Children Is Unduplicated) 940 55569.25000 144855.1600 2.6068
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Total 58851.500000 239651.6900 4.0721
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Number of Children (Unduplicated) With at Least One Service 1364
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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 1 1.000000 37.0000 0.0000
P 1 1.000000 10.0000 9.2500
D 10 9.750000 427.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 3982 27623.500000 49008.5500 49008.5500
T 8 5.000000 76.2500 76.2500
14974 31211.250000 190092.3900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18976 58851.500000 239651.6900 49094.0500