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: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 781 1234.250000 45639.5000 36.9775
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 680 800.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 991 2991.250000 110409.0000 36.9107
Subtotal (Total Children Is Unduplicated) 1129 5025.750000 156048.5000 31.0498
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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 10 20.000000 1537.5000 76.8750
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 68.000000 3774.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 30.500000 2287.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 37.500000 2812.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 18.500000 1387.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 216 355.500000 19730.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 220 365.500000 27412.5000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 311 1000.750000 66229.9700 66.1803
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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 309 818.500000 40837.5000 49.8931
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 586 1830.000000 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 681 3879.500000 193975.0000 50.0000
INTR-T1013-INTERPRETER 1 4.250000 297.5000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 853 6565.000000 65640.0000 9.9985
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 9 32.000000 2286.0800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 27.7600 13.8800
TRAV-TRAVS-Travel by mile 505 50760.00000 22594.1100 0.4451
Subtotal (Total Children Is Unduplicated) 863 64103.25000 337711.2500 5.2682
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Total 70129.750000 559989.7200 7.9851
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Number of Children (Unduplicated) With at Least One Service 1214
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Center 53
Flag Claims Units Chgs Paid
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R 1048 972.750000 42853.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 238 175.250000 7001.7500 0.0000
P 1702 1732.834190 79392.8698 78128.6200
D 4 5.000000 295.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 4673 32942.000000 58170.9400 58170.9400
T 1724 12117.250000 21157.2300 21157.2300
15442 22159.915810 349707.8002 0.0000
Other 20 24.750000 1409.8800 0.0000
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Total 24851 70129.750000 559989.7200 157456.7900