CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 1656 3520.500000 130230.7500 36.9921
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 786 715.250000 71.4400 0.0999
TCM-T1017TL-TARGETED CASE MANAGEMENT 1756 5802.250000 214664.7500 36.9968
Subtotal (Total Children Is Unduplicated) 1947 10038.00000 344966.9400 34.3661
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 101 196.750000 9837.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 23.500000 1660.0200 70.6391
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 11.000000 770.0000 70.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 16.500000 1237.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 22.500000 1535.0200 68.2231
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 20.500000 1072.7500 52.3293
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 216 323.500000 23276.7700 71.9529
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 148 195.000000 14201.5200 72.8283
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 236 363.500000 27172.7900 74.7532
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 290 435.500000 23530.5200 54.0310
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 213 309.000000 22482.1900 72.7579
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 2.000000 100.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 34 168.000000 8400.0000 50.0000
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 671 2091.250000 135602.6300 64.8429
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 154 233.250000 11662.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 36 36.750000 918.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 41 74.250000 3712.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 19 26.000000 1300.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 39 53.250000 2662.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 9.000000 225.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 53 90.000000 4500.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 6.500000 162.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1075 7665.250000 383262.5000 50.0000
INTR-T1013-INTERPRETER 108 290.250000 14292.5000 49.2420
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 73 461.000000 4610.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 124 958.000000 66269.5500 69.1749
PHY-97110-PT SESSION BY LICENSED PT 193 1468.000000 103506.9400 70.5088
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 385 3418.000000 236706.5200 69.2529
TRAV-TRAVS-Travel by mile 1346 139670.0000 61810.0800 0.4425
Subtotal (Total Children Is Unduplicated) 1545 154467.5000 896193.8400 5.8018
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Total 166596.750000 1376763.4100 8.2640
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Number of Children (Unduplicated) With at Least One Service 2031
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Center 09
Flag Claims Units Chgs Paid
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R 2 3.500000 129.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 229 209.250000 8238.2500 27.7500
P 19705 154184.000000 885242.3100 885400.7100
D 8 11.000000 726.5700 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.750000 27.7500 27.7500
3008 11887.250000 460083.0300 276.4600
Other 207 301.000000 22316.0000 0.0000
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Total 23160 166596.750000 1376763.4100 885732.6700