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
Agency Filter:EXT
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
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 4 7.500000 375.0000 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 26 48.500000 3637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 65.500000 4912.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 37.500000 2812.5000 75.0000
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) 111 202.500000 14232.0700 70.2818
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 139 231.500000 11575.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 27 20.250000 506.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 15 17.000000 850.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 20.000000 1000.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 14.000000 700.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 30 33.000000 1650.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 300 1828.000000 91400.0000 50.0000
INTR-T1013-INTERPRETER 4 69.000000 3128.0000 45.3333
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 72 511.000000 5110.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 35 195.000000 13930.8000 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 201 1329.000000 90896.5800 68.3947
TRAV-TRAVS-Travel by mile 1274 107735.0000 47651.1500 0.4423
Subtotal (Total Children Is Unduplicated) 1312 112413.7500 298157.1200 2.6523
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Total 112616.250000 312389.1900 2.7739
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Number of Children (Unduplicated) With at Least One Service 1357
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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 4780 112561.750000 310656.7200 310656.7200
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
13 52.500000 1582.4700 0.0000
Other 1 2.000000 150.0000 0.0000
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Total 4794 112616.250000 312389.1900 310656.7200