CMS/EIP Fiscal Report Center: 51
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 611 835.000000 30848.7500 36.9446
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 215 246.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 596 1676.750000 61956.5000 36.9504
Subtotal (Total Children Is Unduplicated) 727 2757.750000 92805.2500 33.6525
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 75.0000 37.5000
EXIT-EXIT-EXIT ASSESSMENT 46 46.000000 2300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 91 91.500000 6862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 22.000000 1650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 111 113.000000 6271.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 12.500000 937.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 13 13.000000 663.6500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 218 351.000000 21749.7000 61.9650
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 6.000000 2336.2900 389.3817
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 1 2.000000 460.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 4.500000 225.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 5.000000 210.0000 42.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 3.000000 150.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 184 1080.250000 53682.5000 49.6945
INTR-T1013-INTERPRETER 1 3.000000 120.0000 40.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 537 3317.000000 33160.0000 9.9970
OCCT-97530-OT SESSION BY LICENSED OT 119 445.500000 30774.1200 69.0777
OCCT-97530HM-OT SESSION BY OT ASST 86 342.000000 19562.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 64 315.750000 22416.4400 70.9943
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 247 1489.750000 104356.4200 70.0496
SPL-92508-GROUP SPL SESSION PER CHILD 5 18.000000 249.8400 13.8800
TRAV-TRAVS-Travel by mile 19 2867.000000 1275.2500 0.4448
Subtotal (Total Children Is Unduplicated) 578 9901.750000 269128.2600 27.1799
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Total 13010.500000 383683.2100 29.4903
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Number of Children (Unduplicated) With at Least One Service 939
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Center 51
Flag Claims Units Chgs Paid
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R 5 5.000000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 636 422.000000 16791.2500 0.0000
P 1714 8010.750000 155258.6300 155389.1300
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 0 0.000000 0.0000 0.0000
4689 4572.750000 211355.8300 30.0000
Other 0 0.000000 0.0000 0.0000
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Total 7044 13010.500000 383683.2100 155419.1300