CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 292 144.250000 5318.7500 36.8718
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 213 139.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 746 2029.750000 74481.0000 36.6947
Subtotal (Total Children Is Unduplicated) 801 2313.750000 79799.7500 34.4894
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Screening, Eval, and Assessment,Class #02
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 70.4000 70.4000
EXIT-EXIT-EXIT ASSESSMENT 4 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 16.000000 888.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 189 393.000000 28405.6700 72.2791
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 85 191.000000 13425.1300 70.2886
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 37 72.000000 5236.9900 72.7360
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 198 386.000000 21423.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 24.000000 1800.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 459.4500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 4.000000 153.1500 38.2875
SCREEN-T1023-SCREENING 26 26.000000 1300.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 14 14.000000 714.7000 51.0500
Subtotal (Total Children Is Unduplicated) 265 1165.000000 75831.7400 65.0916
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 118 131.750000 6587.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 122 188.250000 9412.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 6 3.750000 93.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 111 245.500000 12275.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.250000 6.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 35 37.250000 1862.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 1.500000 37.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 76 93.000000 4650.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.750000 18.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 79 111.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 353 2088.250000 103712.5000 49.6648
INTR-T1013-INTERPRETER 8 50.500000 2525.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 634 4752.000000 47520.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 90 407.000000 28718.8800 70.5624
OCCT-97530HM-OT SESSION BY OT ASST 44 291.500000 16559.4000 56.8075
PHY-97110-PT SESSION BY LICENSED PT 74 404.750000 28033.0400 69.2601
PHY-97110HM-PT SESSION BY PT ASST 5 20.000000 1143.2000 57.1600
SENS-HA_INS-SENSORY AID INSURANCE PER EAR 1 1.000000 525.0000 525.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 228 1255.250000 85907.8200 68.4388
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.750000 52.0500 13.8800
TRAV-TRAVS-Travel by mile 579 48186.00000 21439.0500 0.4449
Subtotal (Total Children Is Unduplicated) 737 58275.25000 371117.1900 6.3684
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Total 61754.000000 526748.6800 8.5298
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Number of Children (Unduplicated) With at Least One Service 911
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Center 52
Flag Claims Units Chgs Paid
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R 15 12.750000 743.3900 0.0000
U 0 0.000000 0.0000 0.0000
B 289 301.750000 14234.5800 0.0000
P 1938 2045.250000 95829.5700 92468.9800
D 1 2.000000 150.0000 0.0000
S 144 109.750000 3335.7500 75.0000
H 117 143.500000 9897.8500 0.0000
T 6032 54997.250000 193360.9500 182050.8400
3149 4141.750000 209196.5900 409.2600
Other 0 0.000000 0.0000 0.0000
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Total 11685 61754.000000 526748.6800 275004.0800