CMS/EIP Fiscal Report Center: 54
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: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 671 397.500000 14679.7500 36.9302
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 737 925.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 315 790.250000 29146.7500 36.8829
Subtotal (Total Children Is Unduplicated) 1112 2112.750000 43826.5000 20.7438
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 9 9.000000 436.5000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 12.6100 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 16.5200 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 25.3100 25.3100
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 34.9700 34.9700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 18.5500 18.5500
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
EXIT-EXIT-EXIT ASSESSMENT 37 63.750000 3187.5000 50.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 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 19 33.500000 2512.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 39.000000 2164.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 8.500000 637.5000 75.0000
Subtotal (Total Children Is Unduplicated) 91 179.750000 10333.5200 57.4883
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 7.000000 2641.6300 377.3757
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 49 51.250000 2562.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 548 1040.500000 51975.0000 49.9519
CONIP-CONIP-CONSULT, ITDS PHONE 19 8.250000 206.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 17 20.000000 1000.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 5.000000 366.6000 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 575 1685.750000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 69.750000 3487.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 104 548.430000 27409.0000 49.9772
INTR-T1013-INTERPRETER 30 158.750000 4173.7500 26.2913
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1045 9474.000000 94710.0000 9.9968
OCCT-97530-OT SESSION BY LICENSED OT 10 39.760000 2840.3100 71.4364
PHY-97110-PT SESSION BY LICENSED PT 12 54.200000 3869.6600 71.3959
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 8.000000 571.5200 71.4400
TRAV-TRAVS-Travel by mile 802 88663.00000 39466.5700 0.4451
Subtotal (Total Children Is Unduplicated) 1052 101838.1400 235403.7900 2.3115
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Total 104130.640000 289563.8100 2.7808
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Number of Children (Unduplicated) With at Least One Service 1306
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Center 54
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 6143 40696.570000 77484.6800 77484.6800
T 3261 23411.250000 39668.9700 39246.7400
14948 40022.820000 172410.1600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 24352 104130.640000 289563.8100 116731.4200