CMS/EIP Fiscal Report Center: 09
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1517 3650.250000 135059.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 741 638.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 645 2243.750000 82991.0000 36.9876
Subtotal (Total Children Is Unduplicated) 1695 6532.750000 218050.2500 33.3780
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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 119 238.000000 11900.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 50.000000 3750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 92.5000 61.6667
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 65.500000 4912.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 17.500000 971.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 42.500000 3135.0200 73.7652
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 15 29.000000 1450.0000 50.0000
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 2.000000 76.5700 38.2850
Subtotal (Total Children Is Unduplicated) 232 458.500000 27255.8400 59.4457
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 157 272.750000 13637.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 31 24.250000 606.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 17 20.000000 1000.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 20.000000 1000.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 18 20.000000 1000.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 33 39.000000 1950.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 167 172.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 313 1897.000000 94850.0000 50.0000
INTR-T1013-INTERPRETER 100 253.500000 12353.0000 48.7298
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 72 511.000000 5110.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 36 197.000000 14073.6800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 63 405.000000 28811.3400 71.1391
SENS-V5050-IN EAR MONAURAL HEARING AID 2 4.000000 912.0000 228.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 205 1336.000000 91396.6600 68.4107
TRAV-TRAVS-Travel by mile 1274 107735.0000 47651.1500 0.4423
Subtotal (Total Children Is Unduplicated) 1414 112908.7500 314387.5800 2.7844
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Total 119900.000000 559693.6700 4.6680
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Number of Children (Unduplicated) With at Least One Service 1885
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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 13445 119808.500000 556581.4500 556581.4500
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
40 87.500000 2851.2200 0.0000
Other 2 4.000000 261.0000 0.0000
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Total 13487 119900.000000 559693.6700 556581.4500