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
Payclass Filters:GR
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 243 795.000000 29378.0000 36.9535
Subtotal (Total Children Is Unduplicated) 1025 2829.500000 75017.5000 26.5126
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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 3 3.500000 175.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 9.500000 712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 14.000000 777.0000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 25.000000 1387.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 28.000000 2100.0000 75.0000
Subtotal (Total Children Is Unduplicated) 47 96.000000 5913.1200 61.5950
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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 4 8.000000 586.5600 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 585 1828.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 65 244.000000 12200.0000 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 3 26.000000 1857.4400 71.4400
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 285.7600 71.4400
TRAV-TRAVS-Travel by mile 505 50760.00000 22594.1100 0.4451
Subtotal (Total Children Is Unduplicated) 863 60352.75000 148608.9700 2.4623
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Total 63278.250000 229539.5900 3.6275
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Number of Children (Unduplicated) With at Least One Service 1169
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Center 53
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 4639 32907.000000 55959.7000 55959.7000
T 1714 12107.250000 20592.9100 20592.9100
11674 18264.000000 152986.9800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18027 63278.250000 229539.5900 76552.6100