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: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 784 1011.500000 37342.2500 36.9177
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 766 1791.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 934 2491.500000 92009.7500 36.9295
Subtotal (Total Children Is Unduplicated) 1153 5294.750000 129352.0000 24.4302
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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 23 47.500000 3562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 24.000000 1800.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 36 71.500000 3968.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 46.000000 3375.0000 73.3696
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 6 10.500000 787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 187 298.500000 16555.7500 55.4631
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 177 296.499970 22199.9978 74.8735
Subtotal (Total Children Is Unduplicated) 278 872.749970 56975.7378 65.2830
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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 310 752.250000 37600.0000 49.9834
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 300 651.000000 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 684 3504.750000 175237.5000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 140.0000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 844 5975.000000 59740.0000 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 5 15.000000 1071.6000 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 480 38761.00000 17236.9300 0.4447
Subtotal (Total Children Is Unduplicated) 845 49849.75000 301723.0800 6.0527
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Total 56017.249970 488050.8178 8.7125
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Number of Children (Unduplicated) With at Least One Service 1190
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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 407 295.500000 10933.5000 0.0000
P 2880 2785.156640 126913.1602 126702.1600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1883 15131.500000 21136.9400 21136.9400
T 1537 10542.740223 17880.8367 17858.3400
15709 27217.853107 308995.2409 0.0000
Other 35 37.000000 1848.6400 0.0000
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Total 22460 56017.249970 488050.8178 165697.4400