CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2018 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 2400 5681.000000 210021.2500 36.9691
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1900 3194.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 819 3353.500000 123921.7500 36.9530
Subtotal (Total Children Is Unduplicated) 2676 12228.50000 333943.0000 27.3086
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.7100 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 9.000000 122.3100 13.5900
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 12 13.000000 115.5800 8.8908
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 4 4.000000 38.0400 9.5100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 17 19.000000 516.1700 27.1668
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 10 10.000000 174.4000 17.4400
EXIT-EXIT-EXIT ASSESSMENT 22 23.250000 1162.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 32.000000 2400.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 29 32.500000 2437.5000 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 5 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 33.000000 1831.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 22.500000 1687.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 57 98.000000 5439.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 58 98.500000 7387.5000 75.0000
SCREEN-T1023-SCREENING 4 6.000000 300.0000 50.0000
Subtotal (Total Children Is Unduplicated) 180 426.750000 25490.0500 59.7306
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.000000 497.7500 165.9167
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 401 357.250000 17862.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 31 12.500000 312.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 17 76.000000 5572.3200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1475 7855.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 14 40.750000 1018.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 160 1147.260400 57363.0200 50.0000
INTR-T1013-INTERPRETER 1 12.000000 770.0000 64.1667
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1747 28247.00000 282410.0000 9.9979
OCCT-97530-OT SESSION BY LICENSED OT 20 101.391096 7243.3800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 22.000000 1571.6800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 108.000000 7651.2000 70.8444
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.000000 41.6400 13.8800
TRAV-TRAVS-Travel by mile 1133 211204.0000 93987.2000 0.4450
Subtotal (Total Children Is Unduplicated) 1755 252385.6515 633809.3500 2.5113
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Total 265040.901496 993242.4000 3.7475
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Number of Children (Unduplicated) With at Least One Service 2734
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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 3 1.750000 64.7500 0.0000
P 2 2.000000 60.0000 59.2500
D 36 40.500000 2057.4500 0.0000
S 0 0.000000 0.0000 0.0000
H 16274 122692.821096 201090.0900 200890.0900
T 10341 82914.750000 124223.6900 124223.6900
51813 59389.080400 665746.4200 50.0000
Other 0 0.000000 0.0000 0.0000
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Total 78469 265040.901496 993242.4000 325223.0300