CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2018 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 2401 5683.750000 210123.0000 36.9691
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1901 3196.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2601 11860.00000 438006.0000 36.9314
Subtotal (Total Children Is Unduplicated) 2798 20740.25000 648129.0000 31.2498
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 3.000000 145.5000 48.5000
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 56.4900 56.4900
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 39.4200 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 12.000000 162.6600 13.5550
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 17 19.000000 169.2400 8.9074
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 7 7.000000 67.0200 9.5743
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 23 26.000000 682.8500 26.2635
AUDE-92585-AUD EVOKED RESPONSE (COMP) 2 2.000000 169.6800 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 13 13.000000 226.3500 17.4115
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 23 24.250000 1212.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 61 133.500033 10012.5025 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 78 167.000000 12525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 42 84.000000 6300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 108 229.000000 12729.0000 55.5852
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 197 330.999999 24749.9999 74.7734
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 125 203.500000 15262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 117 177.000000 13237.5001 74.7881
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 831 1388.076604 76673.0017 55.2369
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 681 1189.000000 88987.5000 74.8423
SCREEN-T1023-SCREENING 5 8.000000 400.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 1205 4031.326636 264724.7642 65.6669
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 8.000000 3909.2700 488.6588
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 2.000000 100.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 2 2.000000 460.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 131 124.250000 6150.7500 49.5030
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 25 11.500000 287.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 727 2220.000000 110931.2500 49.9690
CONIP-CONIP-CONSULT, ITDS PHONE 88 34.750000 862.7500 24.8273
CONOF-CONOF-CONSULT, OT, FACE TO FACE 420 357.000000 17787.5000 49.8249
CONOP-CONOP-CONSULT, OT, PHONE 61 32.500000 812.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 434 412.000000 20537.5000 49.8483
CONPP-CONPP-CONSULT, PT, PHONE 2 2.500000 62.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 401 358.250000 17912.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 31 12.500000 312.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 20 97.000000 7112.0400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1475 7856.500000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 66 143.250000 3581.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1238 16035.74854 802123.4270 50.0210
INTR-T1013-INTERPRETER 1 12.000000 770.0000 64.1667
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1747 28250.00000 282440.0000 9.9979
OCCT-97530-OT SESSION BY LICENSED OT 100 900.500052 64060.8426 71.1392
OCCT-97530HM-OT SESSION BY OT ASST 13 35.000000 2002.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 88 713.250000 50858.2000 71.3049
PHY-97110HM-PT SESSION BY PT ASST 10 16.000000 914.5600 57.1600
SENS-V5264-EARMOLD 1 4.000000 72.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 93 716.000000 50968.0200 71.1844
SPL-92508-GROUP SPL SESSION PER CHILD 9 11.250000 156.1500 13.8800
TRAV-TRAVS-Travel by mile 1133 211238.0000 94002.3400 0.4450
Subtotal (Total Children Is Unduplicated) 1756 269606.7486 1539237.3496 5.7092
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Total 294378.325228 2452091.1138 8.3297
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Number of Children (Unduplicated) With at Least One Service 2823
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Center 53
Flag Claims Units Chgs Paid
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R 10 9.250000 428.9300 0.0000
U 0 0.000000 0.0000 0.0000
B 4771 4377.000000 199825.2200 246.6300
P 11748 11299.231344 523452.1216 525059.1200
D 248 254.579585 14178.1300 0.0000
S 176 172.000000 7694.2300 6270.2700
H 16945 123342.464981 239896.2742 238006.4700
T 10585 83164.100476 138438.9800 138429.7300
62691 70658.948842 1259769.0680 50.0000
Other 983 1100.750000 68408.1600 0.0000
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Total 108157 294378.325228 2452091.1138 908062.2200