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
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 1680 4181.500000 154715.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 752 667.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 761 2823.500000 104451.0000 36.9934
Subtotal (Total Children Is Unduplicated) 1852 7672.500000 259166.5000 33.7786
-----------------------------------------------------------------------------------------------------------------------
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 125 252.500000 12625.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 26.500000 1987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 59 99.500000 7462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 48.000000 2664.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 39.500000 2962.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 5.000000 250.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 15 81.000000 4050.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 240 577.500000 33286.6900 57.6393
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 136 237.250000 11862.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 29 27.500000 687.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 30 46.750000 2337.5000 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 14 17.000000 850.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 31 42.000000 2100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 232 287.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 380 2321.000000 116050.0000 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 40 254.000000 18145.7600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 82 611.000000 43649.8400 71.4400
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 202 1546.000000 110312.9900 71.3538
TRAV-TRAVS-Travel by mile 1341 124274.0000 54939.3400 0.4421
Subtotal (Total Children Is Unduplicated) 1530 130506.5000 382007.9300 2.9271
-----------------------------------------------------------------------------------------------------------------------
Total 138756.500000 674461.1200 4.8608
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2032
-----------------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 15413 133658.500000 658241.1900 658241.1900
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 0 0.000000 0.0000 0.0000
287 5089.000000 15652.1800 0.0000
Other 5 9.000000 567.7500 0.0000
---------------------------------------------------------
Total 15705 138756.500000 674461.1200 658241.1900