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: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 1877 8430.000000 311253.7500 36.9222
Subtotal (Total Children Is Unduplicated) 1877 8430.000000 311253.7500 36.9222
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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 41 74.500000 5587.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 51 95.000000 7125.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 35 69.000000 5175.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 84 163.000000 9046.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 133 218.500000 16312.5000 74.6568
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 85 137.000000 10275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 84 128.500000 9600.0000 74.7082
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 591 976.500000 53858.2500 55.1544
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 503 870.500000 65062.5000 74.7415
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) 863 2743.500000 182690.8400 66.5904
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 50 89.250000 2231.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 967 12101.25000 604923.5000 49.9885
OCCT-97530-OT SESSION BY LICENSED OT 60 414.500000 29505.0000 71.1821
OCCT-97530HM-OT SESSION BY OT ASST 8 11.000000 629.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 65 464.250000 33066.0600 71.2247
PHY-97110HM-PT SESSION BY PT ASST 5 9.000000 514.4400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 46 311.750000 22156.3000 71.0707
Subtotal (Total Children Is Unduplicated) 1026 13401.00000 693025.7500 51.7145
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Total 24574.500000 1186970.3400 48.3009
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Number of Children (Unduplicated) With at Least One Service 1949
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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 4768 4375.250000 199760.4700 246.6300
P 11489 11095.500000 512804.1500 511836.4200
D 92 89.000000 5199.7800 0.0000
S 176 172.000000 7694.2300 6270.2700
H 22 24.000000 1689.8000 0.0000
T 1 0.250000 9.2500 0.0000
8503 8803.000000 459050.4800 0.0000
Other 5 6.250000 333.2500 0.0000
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Total 25066 24574.500000 1186970.3400 518353.3200