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
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 705 419.750000 15503.0000 36.9339
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 885 1089.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1578 4822.000000 177637.0000 36.8389
Subtotal (Total Children Is Unduplicated) 1614 6330.750000 193140.0000 30.5082
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 10 11.000000 533.5000 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 38 64.750000 3237.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 36 63.500000 4762.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 19.500000 1462.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 44.500000 3337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 41 68.500000 3801.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 262 421.000000 31500.0000 74.8219
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 68 93.500000 7012.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 36.500000 2737.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 281 431.000000 23920.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 89 135.000000 10087.5000 74.7222
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 6 6.000000 300.0000 50.0000
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 478 1413.250000 93570.9200 66.2097
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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 551 1048.500000 52375.0000 49.9523
CONIP-CONIP-CONSULT, ITDS PHONE 20 9.250000 231.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 17 20.000000 1000.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 6 11.000000 806.5200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 689 1831.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 69.750000 3487.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 879 5442.000000 272087.5000 49.9977
INTR-T1013-INTERPRETER 30 158.750000 4173.7500 26.2913
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1183 9776.000000 97730.0000 9.9969
OCCT-97530-OT SESSION BY LICENSED OT 26 132.000000 9430.0800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 6.000000 343.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 41 153.000000 10930.3200 71.4400
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 115.000000 8215.6000 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 5 9.000000 124.9200 13.8800
TRAV-TRAVS-Travel by mile 883 90779.00000 40408.4300 0.4451
Subtotal (Total Children Is Unduplicated) 1190 109624.0000 506696.7000 4.6221
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Total 117368.000000 793407.6200 6.7600
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Number of Children (Unduplicated) With at Least One Service 1644
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Center 54
Flag Claims Units Chgs Paid
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R 1535 1276.500000 53894.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3381 2781.000000 123434.3500 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 6313 41568.320000 83472.0100 83472.0100
T 3370 24188.750000 42229.8400 41797.6100
21968 47553.430000 490377.1700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 36567 117368.000000 793407.6200 125269.6200