CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 1680 4181.500000 154715.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 752 667.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1835 6728.500000 248936.0000 36.9973
Subtotal (Total Children Is Unduplicated) 1996 11577.50000 403651.5000 34.8652
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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 3.000000 24.7800 8.2600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 50.6200 25.3100
EXIT-EXIT-EXIT ASSESSMENT 136 274.500000 13725.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 18.000000 1350.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 17.500000 1312.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 16.500000 1237.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 270 415.000000 30204.8500 72.7828
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 74 117.000000 8657.5200 73.9959
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 245 401.000000 29763.7900 74.2239
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 299 507.500000 27292.4800 53.7783
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 223 337.000000 24652.8300 73.1538
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 5.000000 250.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 18 90.000000 4500.0000 50.0000
OCTH-97167-OT EVAL HIGH 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
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 708 2237.500000 144796.8100 64.7137
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 147 260.250000 13012.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 30 28.500000 712.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 32 49.750000 2487.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 22 22.000000 1100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 17 20.000000 1000.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 32 44.000000 2200.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 247 334.500000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1116 8012.500000 400625.0000 50.0000
INTR-T1013-INTERPRETER 125 293.500000 14451.0000 49.2368
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 73 522.000000 5220.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 110 781.000000 55170.1700 70.6404
PHY-97110-PT SESSION BY LICENSED PT 164 1356.500000 96238.1600 70.9459
SENS-V5014-*HEARING AID REPAIR BY MANUFACTURER 1 2.000000 228.0000 114.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 380 3132.000000 220907.0500 70.5323
TRAV-TRAVS-Travel by mile 1383 139699.0000 61771.6900 0.4422
Subtotal (Total Children Is Unduplicated) 1594 154562.0000 875222.0700 5.6626
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Total 168377.000000 1423670.3800 8.4553
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Number of Children (Unduplicated) With at Least One Service 2118
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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 28 29.750000 1150.9500 50.0000
P 20652 154733.000000 943782.2500 944763.3520
D 13 18.500000 1327.1400 0.0000
S 0 0.000000 0.0000 0.0000
H 61 111.500000 7603.3800 0.0000
T 0 0.000000 0.0000 0.0000
3111 13054.250000 438317.1600 74.4000
Other 271 430.000000 31489.5000 0.0000
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Total 24136 168377.000000 1423670.3800 944887.7520