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:TPIN
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 1 2.750000 101.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 2.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 25 76.500000 2830.5000 37.0000
Subtotal (Total Children Is Unduplicated) 25 81.750000 2932.2500 35.8685
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 2.000000 97.0000 48.5000
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 56.4900 56.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 40.3500 13.4500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 53.6600 8.9433
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 28.9800 9.6600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 138.8500 23.1417
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 51.9500 17.3167
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 27.000033 2025.0025 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 20 39.500000 2962.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 31.000000 1740.0000 56.1290
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 51 89.999999 6749.9999 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 58.500000 4387.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 43.500000 3262.5001 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 184 313.576604 17375.7517 55.4115
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 125 220.000000 16537.5000 75.1705
Subtotal (Total Children Is Unduplicated) 269 859.076636 56432.8742 65.6902
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 5.000000 3411.5200 682.3040
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
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 21.000000 1539.7200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 1.500000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 13.250000 331.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 253 2783.488140 139649.4070 50.1706
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 3.000000 30.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 37 384.608956 27312.4626 71.0136
OCCT-97530HM-OT SESSION BY OT ASST 5 24.000000 1372.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 22 227.000000 16220.4600 71.4558
PHY-97110HM-PT SESSION BY PT ASST 4 6.000000 342.9600 57.1600
SENS-V5264-EARMOLD 1 3.000000 54.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 296.250000 21160.5200 71.4279
SPL-92508-GROUP SPL SESSION PER CHILD 7 8.250000 114.5100 13.8800
TRAV-TRAVS-Travel by mile 3 34.000000 15.1400 0.4453
Subtotal (Total Children Is Unduplicated) 308 3816.347096 212214.7496 55.6068
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Total 4757.173732 271579.8738 57.0885
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Number of Children (Unduplicated) With at Least One Service 410
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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 0 0.000000 0.0000 0.0000
P 257 201.731344 10587.9716 13163.4500
D 120 125.079585 6920.9000 0.0000
S 0 0.000000 0.0000 0.0000
H 649 625.643885 37116.3842 37116.3800
T 243 249.100476 14206.0400 14206.0400
2370 2461.118442 134673.6680 0.0000
Other 978 1094.500000 68074.9100 0.0000
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Total 4617 4757.173732 271579.8738 64485.8700