CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 708 563.000000 20831.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 286 328.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 753 952.250000 35233.2500 37.0000
Subtotal (Total Children Is Unduplicated) 873 1843.500000 56064.2500 30.4119
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.7100 19.7100
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
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 3 19.000000 918.2000 48.3263
EXIT-EXIT-EXIT ASSESSMENT 33 39.500000 1975.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 52 96.500000 7135.9600 73.9478
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 52 97.000000 7275.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 101 191.000000 10600.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 49.000000 3675.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 73.6600 36.8300
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 15.5000 15.5000
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 561.5500 51.0500
Subtotal (Total Children Is Unduplicated) 190 525.000000 33180.2100 63.2004
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 9.000000 7634.3400 848.2600
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 43 62.000000 3100.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.250000 31.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 86 72.250000 3612.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 10 5.750000 143.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 28 30.000000 1500.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 9 4.250000 106.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 58 42.500000 2125.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 2.750000 68.7500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 11.000000 806.5200 73.3200
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 170 885.000000 44250.0000 50.0000
INTR-T1013-INTERPRETER 20 59.000000 2950.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 531 3886.000000 38860.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 141.750000 9593.6400 67.6800
PHY-97110-PT SESSION BY LICENSED PT 16 79.000000 4716.2300 59.6991
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 67 421.500000 29934.0600 71.0179
TRAV-TRAVS-Travel by mile 327 24748.00000 11014.7900 0.4451
Subtotal (Total Children Is Unduplicated) 680 30461.00000 160447.0800 5.2673
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Total 32829.500000 249691.5400 7.6057
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Number of Children (Unduplicated) With at Least One Service 1098
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Center 02
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 4 4.000000 40.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5672 15150.250000 140812.5700 138973.7400
341 1036.500000 6041.9000 0.0000
Other 4547 16638.750000 102797.0700 0.0000
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Total 10564 32829.500000 249691.5400 138973.7400