CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 502 224.500000 8232.5000 36.6704
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 739 710.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2621 6241.000000 230537.7500 36.9392
Subtotal (Total Children Is Unduplicated) 2658 7175.750000 238770.2500 33.2746
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 16 16.000000 776.0000 48.5000
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 3.000000 51.5500 17.1833
AUDE-92586-AUD EVOKED RESPONSE (LIMITED) 1 2.000000 59.0600 29.5300
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.500000 75.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 195 385.000000 19137.5000 49.7078
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.500000 548.5200 57.7389
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 27.000000 2025.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 21.000000 1115.5500 53.1214
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 117 201.000000 14149.0700 70.3934
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 345 555.000000 30317.5900 54.6263
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 344 607.500000 45298.5000 74.5654
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 2.000000 58.2000 29.1000
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 164.2000 41.0500
Subtotal (Total Children Is Unduplicated) 682 1840.500000 114082.0400 61.9843
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 6.000000 5095.2400 849.2067
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 35.4900 35.4900
AUDE-V5160-DISPENSING FEE BINAURAL 1 2.000000 57.0300 28.5150
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 171 229.000000 10912.5000 47.6528
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 3.500000 87.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 110 228.250000 11362.5000 49.7809
CONIP-CONIP-CONSULT, ITDS PHONE 4 2.750000 68.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 36 96.500000 4825.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.750000 68.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 41 76.500000 3800.0000 49.6732
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 71 144.500000 7000.0000 48.4429
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 629 3315.750000 165400.0000 49.8831
INTR-T1013-INTERPRETER 105 377.000000 18650.0000 49.4695
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1498 12251.00000 122510.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 31 266.500000 17273.8700 64.8175
PHY-97110-PT SESSION BY LICENSED PT 87 447.500000 30102.4300 67.2680
PHY-97110HM-PT SESSION BY PT ASST 4 6.750000 403.6800 59.8044
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 119 696.250000 43911.8600 63.0691
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 27.7600 13.8800
TRAV-TRAVS-Travel by mile 912 79777.00000 34257.3900 0.4294
Subtotal (Total Children Is Unduplicated) 1690 97933.50000 475899.7500 4.8594
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Total 106949.750000 828752.0400 7.7490
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Number of Children (Unduplicated) With at Least One Service 2961
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Center 01
Flag Claims Units Chgs Paid
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R 616 441.250000 18223.0900 0.0000
U 0 0.000000 0.0000 0.0000
B 745 823.250000 50257.8700 0.0000
P 28059 94608.250000 572189.5000 569353.9500
D 536 1556.000000 14011.8000 0.0000
S 195 534.000000 7809.0900 0.0000
H 158 200.500000 14503.4100 37.0000
T 1408 5071.250000 29066.7300 28966.8200
4500 3120.750000 86762.0800 0.0000
Other 450 594.500000 35928.4700 450.0000
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Total 36667 106949.750000 828752.0400 598807.7700