CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Agency Filter:EXT
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 1 0.750000 27.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.750000 27.7500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 17.9200 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 21.3500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 25.2200 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 16.5200 8.2600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 50.6200 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 18.5500 18.5500
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 30 34.000000 1700.0000 50.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 43.500000 3262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 13.500000 749.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 41.000000 3075.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 74.9100 37.4550
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 14.4300 14.4300
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 76 162.500000 10193.0700 62.7266
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 8.000000 13467.4000 1683.4250
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 25 30.000000 1500.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 43 32.750000 1637.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 8 4.000000 100.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 13 11.000000 550.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 17 19.500000 975.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 7 3.250000 81.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 72 389.250000 19462.5000 50.0000
INTR-T1013-INTERPRETER 24 55.750000 2787.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 418 2899.000000 28990.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 116.750000 8340.6200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 28 107.500000 5538.0100 51.5164
SENS-V5060-BEHIND EAR 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 53 359.500000 25629.0800 71.2909
TRAV-TRAVS-Travel by mile 157 7056.000000 3140.7900 0.4451
Subtotal (Total Children Is Unduplicated) 522 11094.75000 112470.6500 10.1373
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Total 11258.000000 122691.4700 10.8982
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Number of Children (Unduplicated) With at Least One Service 528
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Center 02
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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4604 11256.250000 122592.2800 122231.6800
1 1.000000 71.4400 51.0500
Other 1 0.750000 27.7500 0.0000
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Total 4606 11258.000000 122691.4700 122282.7300