CMS/EIP Fiscal Report Center: 54
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 862 609.000000 22533.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 854 880.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1682 5609.000000 207153.7500 36.9324
Subtotal (Total Children Is Unduplicated) 1729 7098.750000 229686.7500 32.3559
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 16 18.000000 873.0000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 13.8700 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.1600 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 55.6600 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 31 43.750000 2187.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 42.500000 3187.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 25.500000 1912.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 33.500000 2512.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 36 58.000000 3219.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 184 294.500000 22050.0000 74.8727
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 106 150.000000 11250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 42 62.000000 4650.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 240 374.000000 20757.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 109 181.000000 13575.0000 75.0000
SCREEN-T1023-SCREENING 10 10.000000 500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 469 1304.250000 87190.8900 66.8514
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 13 19.000000 2732.8500 143.8342
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 104 123.500000 6146.4400 49.7687
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 483 558.250000 27887.5000 49.9552
CONIP-CONIP-CONSULT, ITDS PHONE 20 5.500000 137.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 332 151.250000 7550.0000 49.9174
CONOP-CONOP-CONSULT, OT, PHONE 4 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 214 110.750000 5525.0000 49.8871
CONPP-CONPP-CONSULT, PT, PHONE 4 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 160 121.000000 6050.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 16 4.000000 100.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 2.000000 146.6400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 890 2303.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 661 3591.000000 179512.5000 49.9896
INTR-T1013-INTERPRETER 28 117.000000 2925.0000 25.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1237 9073.000000 90710.0000 9.9978
OCCT-97530-OT SESSION BY LICENSED OT 118 592.000000 42278.2400 71.4159
PHY-97110-PT SESSION BY LICENSED PT 112 581.750000 41613.8000 71.5321
PHY-97110HM-PT SESSION BY PT ASST 5 5.000000 285.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 120 669.250000 47811.2200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 3 4.000000 55.5200 13.8800
TRAV-TRAVS-Travel by mile 851 55946.00000 24887.1600 0.4448
Subtotal (Total Children Is Unduplicated) 1243 73980.75000 486442.6700 6.5753
-----------------------------------------------------------------------------------------------------------------------
Total 82383.750000 803320.3100 9.7510
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1757
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 110 106.000000 4369.7200 0.0000
U 0 0.000000 0.0000 0.0000
B 3252 2814.250000 134625.1800 145.4400
P 3208 2699.830000 120204.9500 119559.6300
D 108 107.250000 7201.3200 0.0000
S 2 2.000000 10.0000 0.0000
H 38 37.000000 2621.8400 37.0000
T 6455 35566.050000 82224.0500 82224.0500
22449 40876.120000 442179.5400 0.0000
Other 195 175.250000 9883.7100 27.7500
---------------------------------------------------------
Total 35817 82383.750000 803320.3100 201993.8700