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
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 529 309.250000 11442.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 163 132.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1554 6448.750000 238603.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1617 6890.250000 250046.0000 36.2898
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
EXIT-EXIT-EXIT ASSESSMENT 135 242.000000 12100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 23.000000 1725.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 27.000000 1498.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 331 358.500000 26887.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 305 381.000000 21145.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 64.000000 4800.0000 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 18 18.000000 918.9000 51.0500
Subtotal (Total Children Is Unduplicated) 538 1152.500000 71156.1000 61.7407
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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 1081 8588.500000 429425.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1105 9114.000000 91140.0000 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 57 281.250000 20081.7800 71.4019
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 22.000000 1258.4000 57.2000
TRAV-TRAVS-Travel by mile 38 14630.00000 6510.4700 0.4450
Subtotal (Total Children Is Unduplicated) 1153 33290.50000 585902.9900 17.5997
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Total 41333.250000 907105.0900 21.9461
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Number of Children (Unduplicated) With at Least One Service 1812
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Center 57
Flag Claims Units Chgs Paid
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R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2298 2819.500000 106232.2500 0.0000
P 388 394.750000 24413.3300 24224.1300
D 1 1.000000 75.0000 0.0000
S 48 85.500000 2861.1700 2861.1700
H 0 0.000000 0.0000 0.0000
T 4280 27394.000000 289191.4100 289189.6900
6259 10517.000000 480338.7900 295405.9000
Other 52 121.000000 3974.6400 3974.6400
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Total 13327 41333.250000 907105.0900 615655.5300