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
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 862 607.750000 22486.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 853 880.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 488 1621.500000 59829.0000 36.8973
Subtotal (Total Children Is Unduplicated) 1374 3109.500000 82315.7500 26.4723
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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) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
EXIT-EXIT-EXIT ASSESSMENT 29 40.750000 2037.5000 50.0000
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 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 35.500000 2662.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 21.500000 1612.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 47.000000 2608.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 40.000000 3000.0000 75.0000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 116 225.750000 14197.2800 62.8894
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 15.000000 2457.3800 163.8253
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 2300.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 100 453.900000 22694.3500 49.9986
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 19 68.250000 4875.7800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 16 100.000000 7144.0000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 151.250000 10805.3000 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 27.7600 13.8800
TRAV-TRAVS-Travel by mile 851 55946.00000 24887.1600 0.4448
Subtotal (Total Children Is Unduplicated) 1243 69306.90000 220157.3100 3.1766
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Total 72642.150000 316670.3400 4.3593
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Number of Children (Unduplicated) With at Least One Service 1578
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Center 54
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 1 0.250000 0.0000 27.7500
D 11 9.250000 502.6500 0.0000
S 2 2.000000 10.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 6254 35353.400000 70955.2800 70955.2800
19007 37277.250000 245202.4100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 25275 72642.150000 316670.3400 70983.0300