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
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.500000 602.5000 63.4211
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 5.500000 367.5000 66.8182
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 475.0000 67.8571
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 305.5200 40.7360
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 52 81.500000 5877.3700 72.1150
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 49.500000 2993.7900 60.4806
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 42 70.000000 5108.5500 72.9793
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 88 148.000000 7616.5700 51.4633
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 68.500000 4497.3000 65.6540
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 11 44.000000 2200.0000 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
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 190 510.000000 30972.9900 60.7314
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 0.250000 0.0000 0.0000
OCCT-97530-OT SESSION BY LICENSED OT 32 170.500000 10870.6800 63.7577
PHY-97110-PT SESSION BY LICENSED PT 47 329.000000 20668.3600 62.8218
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 96 747.000000 49659.1400 66.4781
Subtotal (Total Children Is Unduplicated) 156 1248.750000 81234.1800 65.0524
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Total 1758.750000 112207.1700 63.7994
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Number of Children (Unduplicated) With at Least One Service 321
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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 0 0.000000 0.0000 0.0000
P 444 928.000000 54695.2800 54840.4900
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
314 747.250000 51486.1800 0.0000
Other 39 61.500000 4515.0000 0.0000
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Total 814 1758.750000 112207.1700 54840.4900