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: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 703 417.250000 15410.5000 36.9335
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 881 1080.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 351 918.000000 33845.7500 36.8690
Subtotal (Total Children Is Unduplicated) 1265 2415.750000 49256.2500 20.3896
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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 31 50.500000 3787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.500000 412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 50.000000 2775.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 10.500000 787.5000 75.0000
Subtotal (Total Children Is Unduplicated) 108 214.250000 12706.5200 59.3070
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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 549 1042.000000 52050.0000 49.9520
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 3 5.000000 366.6000 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 686 1814.000000 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 1183 9751.000000 97480.0000 9.9969
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 883 90779.00000 40408.4300 0.4451
Subtotal (Total Children Is Unduplicated) 1190 104361.8900 239215.6500 2.2922
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Total 106991.890000 301178.4200 2.8150
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Number of Children (Unduplicated) With at Least One Service 1462
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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 6220 41475.070000 78461.7400 78461.7400
T 3348 24165.750000 40950.6400 40518.4100
15744 41351.070000 181766.0400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 25312 106991.890000 301178.4200 118980.1500