CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 1
List order: No List
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
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 12 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 16.000000 888.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 20.000000 1500.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 15 15.000000 765.7500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 13 13.000000 663.6500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 612.6000 51.0500
Subtotal (Total Children Is Unduplicated) 65 102.500000 6179.8000 60.2907
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 3.000000 150.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 51 51.000000 2550.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 143 142.000000 7100.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 92.000000 2300.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1080 8581.500000 429075.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1102 9105.000000 91050.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 32 143.250000 10233.7800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.500000 85.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 49 134.000000 9572.9600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 10 80.000000 4572.8000 57.1600
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 170.250000 12151.9400 71.3770
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 22.000000 1258.4000 57.2000
TRAV-TRAVS-Travel by mile 37 14485.00000 6445.9400 0.4450
Subtotal (Total Children Is Unduplicated) 1144 33018.50000 577468.6200 17.4892
-----------------------------------------------------------------------------------------------------------------------
Total 33121.000000 583648.4200 17.6217
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1158
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 23 13.000000 908.3300 908.3300
D 0 0.000000 0.0000 0.0000
S 48 85.500000 2861.1700 2861.1700
H 0 0.000000 0.0000 0.0000
T 4269 27229.000000 288400.8800 288399.1600
1729 5672.500000 287503.4000 287190.7500
Other 52 121.000000 3974.6400 3974.6400
---------------------------------------------------------
Total 6121 33121.000000 583648.4200 583334.0500