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
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 827 686.750000 25409.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 317 371.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 265 366.750000 13569.7500 37.0000
Subtotal (Total Children Is Unduplicated) 876 1425.000000 38979.5000 27.3540
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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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 40.000000 3000.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 52.000000 3900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 105.500000 5855.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 25.500000 1912.5000 75.0000
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 115 281.250000 17466.9900 62.1049
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 5.000000 676.4700 135.2940
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 134 743.500000 37175.0000 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 10 53.500000 3822.0400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 14 56.500000 4036.3600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 50.750000 3625.5800 71.4400
TRAV-TRAVS-Travel by mile 365 25182.00000 11203.5700 0.4449
Subtotal (Total Children Is Unduplicated) 741 29502.00000 105359.0200 3.5713
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Total 31208.250000 161805.5100 5.1847
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Number of Children (Unduplicated) With at Least One Service 1127
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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 4598 14478.750000 93219.2700 93183.1200
37 33.500000 568.6000 0.0000
Other 3942 16696.000000 68017.6400 0.0000
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Total 8577 31208.250000 161805.5100 93183.1200