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: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 1594 3734.000000 138158.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 801 670.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 701 2399.000000 88735.2500 36.9884
Subtotal (Total Children Is Unduplicated) 1802 6803.750000 226893.2500 33.3483
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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 33 60.500000 4537.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 205.0000 68.3333
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 48 80.500000 6037.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 21.000000 1165.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 60.500000 4485.0200 74.1326
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) 259 507.000000 30825.0900 60.7990
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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 170 175.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 313 1897.000000 94850.0000 50.0000
INTR-T1013-INTERPRETER 107 269.500000 13153.0000 48.8052
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 64 406.000000 28882.7800 71.1399
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 1283 108139.0000 47830.9500 0.4423
Subtotal (Total Children Is Unduplicated) 1432 113332.7500 315438.8200 2.7833
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Total 120643.500000 573157.1600 4.7508
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Number of Children (Unduplicated) With at Least One Service 1995
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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 13761 120552.000000 570044.9400 570044.9400
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 13803 120643.500000 573157.1600 570044.9400