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: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 855 2137.250000 78856.2500 36.8961
Subtotal (Total Children Is Unduplicated) 855 2137.250000 78856.2500 36.8961
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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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 11.500000 862.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 11.000000 825.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 24.500000 1359.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 58.500000 4387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 42.000000 3150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 47.500000 3525.0000 74.2105
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 161 259.500000 14286.7500 55.0549
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 122 206.500000 15412.5000 74.6368
SCREEN-T1023-SCREENING 1 2.000000 100.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 229 679.000000 44982.5900 66.2483
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 16 22.250000 556.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 461 2457.500000 122875.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 44 176.500000 12573.4800 71.2378
OCCT-97530HM-OT SESSION BY OT ASST 7 7.000000 400.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 53 289.250000 20649.7400 71.3906
PHY-97110HM-PT SESSION BY PT ASST 3 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 172.500000 12265.8400 71.1063
Subtotal (Total Children Is Unduplicated) 566 3128.000000 169492.1900 54.1855
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Total 5944.250000 293331.0300 49.3470
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Number of Children (Unduplicated) With at Least One Service 1012
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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 2922 2691.750000 127086.0900 18.5000
P 1188 1128.250000 53825.1000 53800.1000
D 35 32.000000 1958.9000 0.0000
S 46 47.000000 1937.9600 1652.2000
H 14 16.000000 1118.2800 0.0000
T 1 0.250000 9.2500 0.0000
1963 2018.500000 106933.2700 0.0000
Other 2 2.250000 83.2500 0.0000
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Total 6180 5944.250000 293331.0300 55470.8000