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
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 1028 1621.500000 59958.5000 36.9772
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 711 833.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 329 854.000000 31561.0000 36.9567
Subtotal (Total Children Is Unduplicated) 1209 3308.500000 91519.5000 27.6619
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.1600 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 9 10.750000 537.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 20.000000 1110.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 30.000000 2250.0000 75.0000
SCREEN-T1023-SCREENING 4 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 45 96.750000 6170.1500 63.7742
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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 2036.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 35 157.000000 7850.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 874 5592.000000 55920.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 8.000000 571.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 20.000000 1428.8000 71.4400
TRAV-TRAVS-Travel by mile 442 29180.00000 12981.2300 0.4449
Subtotal (Total Children Is Unduplicated) 877 37768.00000 117093.5300 3.1003
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Total 41173.250000 214783.1800 5.2166
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Number of Children (Unduplicated) With at Least One Service 1352
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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 3 3.000000 77.7500 96.2500
D 7 6.500000 240.5000 0.0000
S 3 2.500000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2729 17904.000000 32176.6800 32176.6800
14289 23257.250000 182288.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 17031 41173.250000 214783.1800 32272.9300