CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 756 654.000000 24190.7500 36.9889
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 434 555.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 747 1318.750000 48793.7500 37.0000
Subtotal (Total Children Is Unduplicated) 864 2527.750000 72984.5000 28.8733
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 12.6100 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 8.2600 8.2600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 25.3100 25.3100
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 33 39.500000 1975.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 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 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 76 140.000000 10395.0000 74.2500
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 56 104.000000 7800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 80 141.500000 7853.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 29.500000 2212.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 26.0500 26.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 1 2.000000 100.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 196 485.000000 31911.1800 65.7962
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 13.000000 15332.3400 1179.4108
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 56 72.000000 3600.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 58 50.750000 2537.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 17.250000 862.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 2.250000 56.2500 25.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 1.250000 31.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 41 28.000000 1400.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 135 741.500000 37075.0000 50.0000
INTR-T1013-INTERPRETER 18 62.000000 3100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 414 2897.000000 28970.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 212.750000 14027.3600 65.9335
PHY-97110-PT SESSION BY LICENSED PT 39 166.750000 10206.2000 61.2066
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 87 676.000000 48293.4400 71.4400
TRAV-TRAVS-Travel by mile 309 17240.00000 7673.7500 0.4451
Subtotal (Total Children Is Unduplicated) 629 22182.50000 173215.5900 7.8087
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Total 25195.250000 278111.2700 11.0382
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Number of Children (Unduplicated) With at Least One Service 1010
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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 4648 9028.750000 143587.5800 142263.2940
404 447.250000 8088.9100 0.0000
Other 5655 15719.250000 126434.7800 0.0000
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Total 10707 25195.250000 278111.2700 142263.2940