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
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 529 309.250000 11442.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 163 132.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 626 2653.000000 98161.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1044 3094.500000 109603.2500 35.4187
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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 5 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 32.000000 2400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 36.000000 1998.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 9.000000 675.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 11 11.000000 561.5500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 197 361.000000 19467.2500 53.9259
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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 141 140.000000 7000.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 164 1002.000000 50100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1100 9055.000000 90550.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 74.250000 5304.4200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.500000 85.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 17 56.500000 4036.3600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 6 38.000000 2172.0800 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 22 95.750000 6840.3800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.000000 228.8000 57.2000
TRAV-TRAVS-Travel by mile 38 14630.00000 6510.4700 0.4450
Subtotal (Total Children Is Unduplicated) 1116 25159.00000 176450.3100 7.0134
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Total 28614.500000 305520.8100 10.6771
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Number of Children (Unduplicated) With at Least One Service 1546
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Center 57
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 39 68.000000 2012.5700 2012.5700
H 0 0.000000 0.0000 0.0000
T 3575 25043.000000 170733.5900 170731.8700
3390 3498.500000 132684.6500 5580.1000
Other 2 5.000000 90.0000 90.0000
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Total 7006 28614.500000 305520.8100 178414.5400