CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2019 ending 06/30/2020 Date of Report:07/21/2020 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 2488 6763.750000 250110.7500 36.9781
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1609 2398.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 862 3550.000000 131257.0000 36.9738
Subtotal (Total Children Is Unduplicated) 2712 12712.50000 381367.7500 29.9994
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.7100 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 41.6100 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 54.4800 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 29.8800 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 194.8100 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.000000 83.5000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 22.4000 22.4000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 4 5.000000 250.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 18 21.750000 1087.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 22.500000 1687.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 13.000000 975.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 30.000000 2250.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 28.000000 2100.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 60 98.000000 5439.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 22.500000 1248.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 72.000000 5400.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 17.000000 1275.0000 75.0000
SCREEN-T1023-SCREENING 5 9.000000 450.0000 50.0000
Subtotal (Total Children Is Unduplicated) 165 397.750000 24875.1400 62.5396
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 5.000000 245.6600 49.1320
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 76 65.000000 3250.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 12 11.500000 575.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 25 19.500000 487.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 582 1332.000000 66562.5000 49.9718
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 284 391.000000 19550.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 44 23.750000 593.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 446 427.750000 21387.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 237 190.000000 9500.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 76 39.750000 993.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 399 362.500000 18125.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 174 107.750000 5387.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 4.500000 112.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 410 377.750000 18862.5000 49.9338
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 234 224.750000 11225.0000 49.9444
CONSP-CONSP-CONSULT, SLP, PHONE 34 18.750000 468.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1193 5630.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 52.000000 1300.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 132 797.000000 39850.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 42 167.500000 8375.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1481 17330.00000 173280.0000 9.9988
OCCT-97530-OT SESSION BY LICENSED OT 19 72.500000 5179.4000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 7 29.750000 2125.3400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 36.000000 2571.8400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 96.500000 6893.9600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 24.000000 1714.5600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 97 196.750000 7279.7500 37.0000
TRAV-TRAVS-Travel by mile 938 138385.0000 61562.5700 0.4449
Subtotal (Total Children Is Unduplicated) 1561 166421.0000 487544.6500 2.9296
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Total 179531.250000 893787.5400 4.9785
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Number of Children (Unduplicated) With at Least One Service 2765
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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 1 0.500000 18.5000 0.0000
P 4 2.250000 46.2500 27.7500
D 205 213.750000 9200.3300 0.0000
S 10 152.500000 103.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 19564 148221.500000 248952.9700 248283.4700
42249 30940.750000 635466.1900 37.0000
Other 0 0.000000 0.0000 0.0000
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Total 62033 179531.250000 893787.5400 248348.2200