CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 247 102.750000 3801.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 37 27.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1381 4314.250000 159627.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1389 4444.750000 163429.0000 36.7690
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 102 183.000000 9150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 8.000000 600.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 2.500000 168.0000 67.2000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 235 195.500000 14662.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 24.000000 1800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 350 341.500000 18953.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 128 133.500000 10012.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 29.000000 1480.4500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 10 10.000000 510.5000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 22 22.000000 1123.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 71 71.000000 3624.5500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 604 1047.000000 63584.2500 60.7299
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 48 48.000000 2400.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 6.000000 300.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 158 156.500000 7825.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 16 506.000000 12650.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 923 7238.000000 361900.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1009 8310.000000 83100.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 69 342.181700 24445.4600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 25 71.500000 4089.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 85 368.000000 26289.9200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 31 231.250000 13218.2500 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 135 643.000000 45935.9200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 24 62.000000 3546.4000 57.2000
TRAV-TRAVS-Travel by mile 32 9742.000000 4335.3000 0.4450
Subtotal (Total Children Is Unduplicated) 1168 27728.43170 590382.0500 21.2916
-----------------------------------------------------------------------------------------------------------------------
Total 33220.181700 817395.3000 24.6054
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1747
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2494 2567.000000 102851.0000 0.0000
P 269 231.113400 11041.3300 11041.3800
D 15 20.250000 805.7500 0.0000
S 96 80.250000 3392.8200 3393.8700
H 0 0.000000 0.0000 0.0000
T 3862 21323.250000 273912.7800 273910.9500
4393 8782.318300 420527.4100 317967.8300
Other 103 216.000000 4864.2100 4904.2100
---------------------------------------------------------
Total 11232 33220.181700 817395.3000 611218.2400