CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 755 627.750000 23226.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 326 466.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 165 265.000000 9805.0000 37.0000
Subtotal (Total Children Is Unduplicated) 782 1359.500000 33031.7500 24.2970
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 17.9200 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 21.3500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 25.2200 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 16.5200 8.2600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 50.6200 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 18.5500 18.5500
EXIT-EXIT-EXIT ASSESSMENT 40 48.500000 2425.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 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 14 26.500000 1987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 23.000000 1725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 46.500000 2580.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 55.000000 4125.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 101 222.500000 13830.6300 62.1601
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 7.000000 12127.4000 1732.4857
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 41 50.500000 2525.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 74 53.750000 2687.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 9 4.500000 112.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 29 21.500000 1075.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 48 36.750000 1837.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 9 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 104 529.750000 26487.5000 50.0000
INTR-T1013-INTERPRETER 28 64.250000 3212.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 422 2904.000000 29040.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 71.250000 5090.1000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 14 62.000000 4077.7000 65.7694
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 34 204.000000 14573.7600 71.4400
TRAV-TRAVS-Travel by mile 318 19000.00000 8456.9300 0.4451
Subtotal (Total Children Is Unduplicated) 624 23013.75000 111428.3900 4.8418
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Total 24595.750000 158290.7700 6.4357
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Number of Children (Unduplicated) With at Least One Service 953
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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 4349 11603.750000 104366.3700 104012.7700
1 1.000000 71.4400 51.0500
Other 3210 12991.000000 53852.9600 0.0000
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Total 7560 24595.750000 158290.7700 104063.8200