CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 827 686.750000 25409.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 317 371.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 872 1135.750000 42022.7500 37.0000
Subtotal (Total Children Is Unduplicated) 990 2194.000000 67432.5000 30.7350
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
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
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 36 49.250000 2462.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 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 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 72 128.000000 9600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 61 115.000000 8625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 142 258.000000 14319.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 27.500000 2062.5000 75.0000
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
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 54.3600 27.1800
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 222 604.750000 38447.3000 63.5755
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 7.000000 930.4700 132.9243
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 53 70.000000 3500.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 61 52.000000 2600.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 21 22.750000 1137.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 40 33.000000 1650.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 181 923.250000 46162.5000 50.0000
INTR-T1013-INTERPRETER 25 88.500000 4425.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 516 3142.000000 31420.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 125.500000 8757.5600 69.7814
PHY-97110-PT SESSION BY LICENSED PT 29 111.750000 7489.6600 67.0216
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 258.250000 18420.8000 71.3293
TRAV-TRAVS-Travel by mile 365 25182.00000 11203.5700 0.4449
Subtotal (Total Children Is Unduplicated) 750 30018.50000 137784.5600 4.5900
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Total 32817.250000 243664.3600 7.4249
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Number of Children (Unduplicated) With at Least One Service 1199
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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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5036 14861.000000 119940.8900 119904.7400
41 36.500000 731.0800 0.0000
Other 5716 17919.750000 122992.3900 0.0000
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Total 10793 32817.250000 243664.3600 119904.7400