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
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 1656 3520.500000 130230.7500 36.9921
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 774 642.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 721 2496.500000 92370.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1822 6659.250000 222601.2500 33.4274
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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 4 7.500000 460.0200 61.3360
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.000000 95.0000 47.5000
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 5 8.500000 485.0200 57.0612
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.500000 351.2500 46.8333
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 52 79.500000 5056.7700 63.6072
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 31.000000 1964.0200 63.3555
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 83 129.000000 9585.2900 74.3046
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 77.500000 3814.0000 49.2129
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 79 117.000000 8107.1900 69.2922
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 293 665.250000 40457.1100 60.8149
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 125 186.000000 9300.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 28 28.000000 700.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 24 34.750000 1737.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 15 22.000000 1100.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 25 28.000000 1400.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 34 53.000000 2650.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 5.500000 137.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 301 1760.750000 88037.5000 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 54 286.000000 18349.3100 64.1584
PHY-97110-PT SESSION BY LICENSED PT 89 509.000000 35278.0300 69.3085
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 240 1547.500000 103349.6000 66.7849
TRAV-TRAVS-Travel by mile 1166 96362.00000 42634.1700 0.4424
Subtotal (Total Children Is Unduplicated) 1308 101583.7500 324218.1100 3.1916
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Total 108908.250000 587276.4700 5.3924
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Number of Children (Unduplicated) With at Least One Service 1947
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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 13269 104524.250000 558144.7800 558144.7800
D 1 1.000000 71.4400 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
499 4383.000000 29060.2500 205.0000
Other 0 0.000000 0.0000 0.0000
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Total 13769 108908.250000 587276.4700 558349.7800