CMS/EIP Fiscal Report Center: 53
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 1028 1621.500000 59958.5000 36.9772
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 711 833.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1186 3181.250000 117428.7500 36.9128
Subtotal (Total Children Is Unduplicated) 1330 5635.750000 177387.2500 31.4754
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 36.3200 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 4 4.000000 39.8400 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 83.4900 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 50.1000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 10 12.750000 637.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.000000 675.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 12.500000 937.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 13.500000 975.0000 72.2222
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 32.000000 1776.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 75.000000 5625.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 55.500000 4162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 43 62.500000 4687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 200 345.500000 19147.5000 55.4197
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 165 293.500000 21975.0000 74.8722
SCREEN-T1023-SCREENING 5 6.000000 300.0000 50.0000
Subtotal (Total Children Is Unduplicated) 326 934.750000 61333.2500 65.6146
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 5.000000 215.1600 43.0320
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 28 24.750000 1237.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 260 419.500000 20975.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 11 4.250000 106.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 141 104.500000 5225.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 9 4.250000 106.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 182 128.500000 6425.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 0.750000 18.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 109 73.500000 3662.5000 49.8299
CONSP-CONSP-CONSULT, SLP, PHONE 2 0.750000 18.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 667 2038.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 23.500000 587.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 481 2447.500000 122375.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 874 5593.000000 55930.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 59 310.000000 22117.9200 71.3481
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 68 415.250000 29651.1800 71.4056
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 71 365.000000 26075.6000 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TRAV-TRAVS-Travel by mile 442 29180.00000 12981.2300 0.4449
Subtotal (Total Children Is Unduplicated) 878 41141.50000 307817.1700 7.4819
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Total 47712.000000 546537.6700 11.4549
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Number of Children (Unduplicated) With at Least One Service 1419
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Center 53
Flag Claims Units Chgs Paid
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R 10 9.500000 454.8200 0.0000
U 0 0.000000 0.0000 0.0000
B 2523 2373.360000 112793.7300 336.5000
P 1828 1732.630000 79677.2600 80595.1400
D 63 63.250000 3731.3300 0.0000
S 4 2.750000 9.2500 0.0000
H 43 42.750000 3054.0600 0.0000
T 2755 17930.000000 33259.2900 33259.2900
16315 25386.760000 303769.7400 0.0000
Other 180 171.000000 9788.1900 0.0000
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Total 23721 47712.000000 546537.6700 114190.9300