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
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 611 835.000000 30848.7500 36.9446
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 215 246.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 227 644.000000 23791.0000 36.9425
Subtotal (Total Children Is Unduplicated) 672 1725.000000 54639.7500 31.6752
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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 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 37.500000 2812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 45.500000 2525.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 5.500000 412.5000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 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 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 121 174.500000 10512.5500 60.2438
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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 48 275.500000 13495.0000 48.9837
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 33 106.750000 7251.5000 67.9297
OCCT-97530HM-OT SESSION BY OT ASST 20 76.000000 4347.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 25 104.500000 7465.4800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 110 546.000000 37926.0800 69.4617
TRAV-TRAVS-Travel by mile 19 2867.000000 1275.2500 0.4448
Subtotal (Total Children Is Unduplicated) 557 7319.250000 108571.8000 14.8337
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Total 9218.750000 173724.1000 18.8446
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Number of Children (Unduplicated) With at Least One Service 903
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Center 51
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 1473 7332.500000 109998.7000 109998.7000
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
2951 1886.250000 63725.4000 30.0000
Other 0 0.000000 0.0000 0.0000
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Total 4424 9218.750000 173724.1000 110028.7000