CMS/EIP Fiscal Report Center: 07
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 1471 1507.000000 55740.5000 36.9877
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 746 738.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 516 1303.500000 48137.0000 36.9290
Subtotal (Total Children Is Unduplicated) 1731 3548.500000 103877.5000 29.2736
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 41.6100 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 27.2400 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 55.6600 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 33.4000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 143 226.000000 11287.5000 49.9447
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 85.500000 6362.5000 74.4152
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 78 154.000000 8547.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 104.986700 7874.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 4.000000 112.8800 28.2200
Subtotal (Total Children Is Unduplicated) 272 613.486700 36191.4400 58.9930
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 2778.8700 1389.4350
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 76 82.000000 4100.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 119 248.000000 12400.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 5 5.000000 125.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 13 27.000000 1350.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 23 38.750000 1937.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 1.500000 37.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 43 63.500000 3175.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 198 227.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 364 2014.250000 99651.9200 49.4735
INTR-T1013-INTERPRETER 3 30.000000 2620.0000 87.3333
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1283 7965.000000 79650.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 51.750000 3002.0200 58.0100
PHY-97110-PT SESSION BY LICENSED PT 8 46.500000 2412.8000 51.8882
PHY-97110HM-PT SESSION BY PT ASST 1 3.500000 4.9400 1.4114
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 39 184.000000 11341.5500 61.6389
TRAV-TRAVS-Travel by mile 13 843.000000 375.0500 0.4449
Subtotal (Total Children Is Unduplicated) 1362 11836.50000 225049.6500 19.0132
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Total 15998.486700 365118.5900 22.8221
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Number of Children (Unduplicated) With at Least One Service 2078
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Center 07
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 3783 11754.250000 232212.2400 232239.9900
D 17 16.250000 727.2500 0.0000
S 53 28.500000 943.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6913 4199.486700 131235.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10766 15998.486700 365118.5900 232239.9900