CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 1594 3734.000000 138158.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 801 670.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1777 6124.000000 226560.2500 36.9955
Subtotal (Total Children Is Unduplicated) 1943 10528.75000 364718.2500 34.6402
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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-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-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 34.9700 34.9700
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.6800 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.000000 345.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 132 264.000000 13200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 17.000000 1165.0000 68.5294
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 7.500000 517.5000 69.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 17.500000 1262.5000 72.1429
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.000000 721.7700 48.1180
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 241 380.000000 28168.4900 74.1276
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 133 189.500000 13473.7900 71.1018
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 204 336.500000 25096.0500 74.5796
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 303 504.000000 27374.5700 54.3146
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 198 290.000000 21057.3200 72.6114
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 27 134.000000 6700.0000 50.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 2.000000 76.5700 38.2850
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 695 2190.000000 140828.5000 64.3053
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 168 298.750000 14937.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 34 26.000000 650.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 23 27.000000 1350.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 22.000000 1100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 18 20.000000 1000.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 35 41.000000 2050.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 255 351.000000 35.7200 0.1018
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1061 7460.750000 373037.5000 50.0000
INTR-T1013-INTERPRETER 107 269.500000 13153.0000 48.8052
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 72 511.000000 5110.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 114 764.500000 53235.4200 69.6343
PHY-97110-PT SESSION BY LICENSED PT 158 1185.000000 81490.2500 68.7681
SENS-V5050-IN EAR MONAURAL HEARING AID 3 5.000000 1140.0000 228.0000
SENS-V5264-EARMOLD 3 5.000000 90.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 390 3412.250000 234989.5400 68.8664
TRAV-TRAVS-Travel by mile 1366 136524.0000 60393.7200 0.4424
Subtotal (Total Children Is Unduplicated) 1559 150923.7500 843787.6500 5.5908
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Total 163642.500000 1349334.4000 8.2456
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Number of Children (Unduplicated) With at Least One Service 2081
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Center 09
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 56 61.750000 3084.7500 0.0000
P 20254 155149.250000 906037.7900 906211.2570
D 17 22.000000 1510.7100 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
2431 8053.000000 412616.9000 0.0000
Other 228 356.500000 26084.2500 0.0000
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Total 22986 163642.500000 1349334.4000 906211.2570