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:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 18 26.750000 989.7500 37.0000
Subtotal (Total Children Is Unduplicated) 18 26.750000 989.7500 37.0000
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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 1.000000 115.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 13 26.000000 1300.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 14.000000 953.6200 68.1157
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 24.500000 1837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 34.000000 1887.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 17.500000 1312.5000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 16 61.000000 3050.0000 50.0000
Subtotal (Total Children Is Unduplicated) 77 189.000000 11250.6200 59.5271
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 16 26.000000 1300.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 1.750000 43.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 6 7.000000 350.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 126 175.500000 35.7200 0.2035
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 133 515.000000 25750.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 59.000000 4144.3400 70.2431
PHY-97110-PT SESSION BY LICENSED PT 20 74.000000 5077.6700 68.6172
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 108 480.250000 33281.1800 69.2997
TRAV-TRAVS-Travel by mile 542 28385.00000 12562.7700 0.4426
Subtotal (Total Children Is Unduplicated) 655 29730.50000 83016.4300 2.7923
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Total 29946.250000 95256.8000 3.1809
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Number of Children (Unduplicated) With at Least One Service 710
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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 1765 29168.000000 93293.3200 93293.3200
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
35 774.250000 1692.7300 0.0000
Other 3 4.000000 270.7500 0.0000
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Total 1803 29946.250000 95256.8000 93293.3200