CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 712 1134.000000 41930.2500 36.9755
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 594 673.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 890 2583.000000 95303.7500 36.8965
Subtotal (Total Children Is Unduplicated) 1025 4390.500000 137234.0000 31.2570
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Screening, Eval, and Assessment,Class #02
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 51.3500 51.3500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 24.7800 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 75.9300 25.3100
EXIT-EXIT-EXIT ASSESSMENT 4 4.750000 237.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 40.000000 3000.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 20 46.500000 3487.5000 75.0000
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 7 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 61.500000 3413.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 27.000000 2025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 29.500000 2212.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 15.500000 1162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 146 246.500000 13680.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 150 255.000000 19125.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 230 754.750000 49994.7200 66.2401
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 417.1000 104.2750
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 71 64.000000 3200.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 6 3.500000 87.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 306 813.000000 40562.5000 49.8924
CONIP-CONIP-CONSULT, ITDS PHONE 45 18.500000 462.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 5 9.000000 659.8800 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 521 1743.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 12 16.000000 400.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 676 3858.500000 192925.0000 50.0000
INTR-T1013-INTERPRETER 1 4.250000 297.5000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 768 6367.000000 63660.0000 9.9984
OCCT-97530-OT SESSION BY LICENSED OT 14 86.000000 6143.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 3 7.000000 500.0800 71.4400
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 29.000000 2071.7600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 27.7600 13.8800
TRAV-TRAVS-Travel by mile 471 49772.00000 22154.3000 0.4451
Subtotal (Total Children Is Unduplicated) 777 62800.75000 333752.1200 5.3145
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Total 67946.000000 520980.8400 7.6676
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Number of Children (Unduplicated) With at Least One Service 1109
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Center 53
Flag Claims Units Chgs Paid
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R 947 870.500000 38154.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 214 153.250000 6103.0000 0.0000
P 1573 1571.673380 71166.2998 70261.3700
D 4 5.000000 295.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 4592 32355.250000 57344.7900 57344.7900
T 1684 11675.750000 20586.1700 20586.1700
14530 21294.076620 326190.7002 0.0000
Other 17 20.500000 1139.6300 0.0000
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Total 23561 67946.000000 520980.8400 148192.3300