CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 Page: 1
List order: No List
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 724 929.500000 34308.2500 36.9104
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 689 1640.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 850 2163.750000 79883.0000 36.9188
Subtotal (Total Children Is Unduplicated) 1065 4733.500000 114191.2500 24.1241
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 6.000000 291.0000 48.5000
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 21.5500 21.5500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 33.0400 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 18.1200 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 75.9300 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 37.1000 18.5500
EXIT-EXIT-EXIT ASSESSMENT 11 10.750000 537.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 36.000000 2700.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 22 45.500000 3412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 23.000000 1725.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 35 70.500000 3912.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 35.000000 2550.0000 72.8571
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 13.500000 1012.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 136 224.500000 12448.7500 55.4510
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 124 215.499970 16124.9978 74.8260
Subtotal (Total Children Is Unduplicated) 218 699.749970 45463.2378 64.9707
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 56.5000 56.5000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 68 85.000000 4250.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 308 743.750000 37175.0000 49.9832
CONIP-CONIP-CONSULT, ITDS PHONE 9 4.250000 106.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 14 30.000000 2199.6000 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 290 642.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 13.000000 325.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 681 3485.750000 174287.5000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 140.0000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 780 5822.000000 58210.0000 9.9983
OCCT-97530-OT SESSION BY LICENSED OT 7 21.000000 1500.2400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 11.000000 785.8400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 25.000000 1786.0000 71.4400
TRAV-TRAVS-Travel by mile 450 37723.00000 16774.9100 0.4447
Subtotal (Total Children Is Unduplicated) 781 48618.25000 298070.3000 6.1308
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Total 54051.499970 457724.7878 8.4683
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Number of Children (Unduplicated) With at Least One Service 1099
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Center 53
Flag Claims Units Chgs Paid
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R 9 7.500000 342.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 348 244.500000 9046.5000 0.0000
P 2631 2497.156640 113461.1602 113250.1600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1850 14681.000000 20709.2100 20709.2100
T 1505 10300.240223 17359.0767 17336.5800
15025 26284.103107 294957.7009 0.0000
Other 35 37.000000 1848.6400 0.0000
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Total 21403 54051.499970 457724.7878 151295.9500