CMS/EIP Fiscal Report Center: 07
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 1388 1346.500000 49820.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 784 901.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1718 4549.250000 168192.7500 36.9715
Subtotal (Total Children Is Unduplicated) 1941 6797.250000 218013.2500 32.0737
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 6.000000 83.2200 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 72.6400 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 9.000000 223.9400 24.8822
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 50.1000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 69 108.000000 5400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 23.500000 1762.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 23.500000 1304.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 158 310.000000 23250.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 184 356.000000 19758.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 174 369.000000 27675.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 6 6.000000 300.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 3 3.000000 153.1500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 97.8800 48.9400
Subtotal (Total Children Is Unduplicated) 416 1254.000000 81844.3300 65.2666
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EI Services,Class #03
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 70 70.250000 3512.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 78 171.250000 8562.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 3.000000 75.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 15.000000 750.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 17.000000 850.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 16 34.000000 1700.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.250000 31.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 169 223.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 320 1408.000000 69979.2100 49.7011
INTR-T1013-INTERPRETER 1 6.000000 300.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1136 6103.000000 60743.3500 9.9530
OCCT-97530-OT SESSION BY LICENSED OT 39 132.000000 9015.0800 68.2961
PHY-97110-PT SESSION BY LICENSED PT 21 135.000000 9310.7000 68.9681
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 112 500.250000 34534.3000 69.0341
TRAV-TRAVS-Travel by mile 17 861.000000 329.7800 0.3830
Subtotal (Total Children Is Unduplicated) 1260 9686.250000 199874.1700 20.6348
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Total 17737.500000 499731.7500 28.1737
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Number of Children (Unduplicated) With at Least One Service 2125
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Center 07
Flag Claims Units Chgs Paid
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R 13 9.500000 351.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 41 36.500000 1439.5000 0.0000
P 6670 12971.250000 350352.5000 350037.7500
D 180 145.750000 6074.7500 0.0000
S 9 68.000000 2620.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6903 4505.500000 138856.5000 0.0000
Other 2 1.000000 37.0000 0.0000
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Total 13818 17737.500000 499731.7500 350037.7500