CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 617 506.500000 18740.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 893 2927.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 303 720.250000 26593.7500 36.9229
Subtotal (Total Children Is Unduplicated) 1125 4154.500000 45334.2500 10.9121
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 5 6.000000 291.0000 48.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 17.5000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 8.0600 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 43.6800 21.8400
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 46.8000 46.8000
EXIT-EXIT-EXIT ASSESSMENT 22 43.500000 2175.0000 50.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 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 15 27.500000 2062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 41.000000 2275.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 18.500000 1387.5000 75.0000
Subtotal (Total Children Is Unduplicated) 69 162.500000 9788.0400 60.2341
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 17 48.640000 8100.3900 166.5376
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 74 37.250000 1862.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 558 864.000000 43200.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 19 7.000000 149.2500 21.3214
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 11.000000 550.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 58.000000 2900.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 154 772.750000 38637.5000 50.0000
INTR-T1013-INTERPRETER 33 115.500000 2887.5000 25.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 993 7793.000000 77920.0000 9.9987
OCCT-97530-OT SESSION BY LICENSED OT 6 16.000000 1143.0400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 14 49.050000 3500.2500 71.3609
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 117.750000 8412.0600 71.4400
TRAV-TRAVS-Travel by mile 624 50408.00000 22438.6300 0.4451
Subtotal (Total Children Is Unduplicated) 993 60297.94000 211701.1200 3.5109
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Total 64614.940000 266823.4100 4.1294
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Number of Children (Unduplicated) With at Least One Service 1214
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Center 54
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 3 3.000000 38.6500 0.0000
H 3456 22299.480000 52549.5100 52549.5100
T 4177 25306.750000 56429.4400 56429.4400
13281 17005.710000 157805.8100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 20917 64614.940000 266823.4100 108978.9500