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
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 502 224.500000 8232.5000 36.6704
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 739 710.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 928 1724.000000 63630.7500 36.9088
Subtotal (Total Children Is Unduplicated) 1663 2658.750000 71863.2500 27.0290
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 15 15.000000 727.5000 48.5000
EXIT-EXIT-EXIT ASSESSMENT 195 385.000000 19137.5000 49.7078
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 15.000000 1087.5000 72.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 42.000000 2220.0000 52.8571
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 24.500000 1837.5000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 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 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 243 486.500000 25265.2500 51.9327
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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-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 119 595.750000 29662.5000 49.7902
INTR-T1013-INTERPRETER 101 364.500000 18025.0000 49.4513
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1498 12251.00000 122510.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 53.000000 3786.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 15 67.000000 4768.6200 71.1734
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 197.000000 13787.9200 69.9894
TRAV-TRAVS-Travel by mile 912 79777.00000 34257.3900 0.4294
Subtotal (Total Children Is Unduplicated) 1604 94099.00000 270167.6700 2.8711
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Total 97244.250000 367296.1700 3.7770
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Number of Children (Unduplicated) With at Least One Service 2438
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Center 01
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 0.250000 9.2500 0.0000
P 18943 87647.750000 265967.4100 266041.4100
D 346 1367.750000 4869.2900 0.0000
S 113 443.500000 2875.5600 0.0000
H 0 0.000000 0.0000 0.0000
T 1169 4829.500000 16092.1800 16081.4600
4348 2952.500000 77268.1600 0.0000
Other 6 3.000000 214.3200 0.0000
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Total 24926 97244.250000 367296.1700 282122.8700