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
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 748 602.250000 22283.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 318 374.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 201 274.000000 10138.0000 37.0000
Subtotal (Total Children Is Unduplicated) 807 1251.000000 32421.2500 25.9163
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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 1 7.000000 341.3200 48.7600
EXIT-EXIT-EXIT ASSESSMENT 32 38.500000 1925.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 38.500000 2887.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 30.500000 2287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 68.000000 3774.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 61.500000 4612.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 15.5000 15.5000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 108 259.000000 16433.2100 63.4487
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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 2 9.000000 659.8800 73.3200
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 127 705.000000 35250.0000 50.0000
INTR-T1013-INTERPRETER 21 64.000000 3200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 533 3888.000000 38880.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 18 85.750000 6125.9800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 21.500000 1535.9600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 34 193.000000 13787.9200 71.4400
TRAV-TRAVS-Travel by mile 357 26876.00000 11961.8400 0.4451
Subtotal (Total Children Is Unduplicated) 703 32072.00000 129723.4200 4.0448
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Total 33582.000000 178577.8800 5.3177
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Number of Children (Unduplicated) With at Least One Service 1068
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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 5252 15425.750000 116628.2800 115426.5800
328 1028.500000 5531.5500 0.0000
Other 3231 17123.750000 56378.0500 0.0000
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Total 8815 33582.000000 178577.8800 115426.5800