CMS/EIP Fiscal Report Center: 10
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 1 0.250000 9.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1195 1053.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1073 3480.000000 128688.0000 36.9793
Subtotal (Total Children Is Unduplicated) 1819 4533.500000 128697.2500 28.3881
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 46 48.000000 860.1600 17.9200
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 49 51.000000 643.1100 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 47 49.000000 404.7400 8.2600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 52 54.000000 1366.7400 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 23 23.000000 426.6500 18.5500
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 4 5.000000 103.4000 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 3 3.000000 135.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 4 7.000000 805.0000 115.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 16.500000 1237.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 112 202.500000 15187.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 76.000000 5700.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 43.500000 3262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 110 195.000000 10822.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 52.500000 3937.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 8 8.000000 408.4000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 408.4000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 241 874.000000 47640.0500 54.5081
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 9.000000 4027.0600 447.4511
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 235 212.500000 10625.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 9 7.250000 181.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 281 269.750000 13487.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 9 11.000000 275.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 27 26.500000 1325.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 61 60.250000 3012.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 372 358.250000 17912.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 12 12.000000 300.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 536 5562.750000 278137.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1729 20931.00000 209310.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 127 681.750000 48704.2200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 137 792.250000 56598.3400 71.4400
SENS-V5050-IN EAR MONAURAL HEARING AID 2 4.000000 912.0000 228.0000
SENS-V5264-EARMOLD 3 8.000000 144.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 216 1363.000000 97372.7200 71.4400
Subtotal (Total Children Is Unduplicated) 1877 30310.25000 742381.7900 24.4928
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Total 35717.750000 918719.0900 25.7216
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Number of Children (Unduplicated) With at Least One Service 2759
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Center 10
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 9896 30571.250000 748242.8400 748242.8400
D 43 25.250000 934.2500 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
6386 5121.250000 169542.0000 60.0000
Other 0 0.000000 0.0000 0.0000
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Total 16325 35717.750000 918719.0900 748302.8400