CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
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 244 100.750000 3727.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 37 27.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1342 4177.500000 154567.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1350 4306.000000 158295.2500 36.7616
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Screening, Eval, and Assessment,Class #02
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 102 183.000000 9150.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 8.000000 600.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 2.500000 168.0000 67.2000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 218 180.000000 13500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 21.000000 1575.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 312 300.500000 16677.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 107 109.000000 8175.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 29.000000 1480.4500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 10 10.000000 510.5000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 22 22.000000 1123.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 71 71.000000 3624.5500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 564 963.000000 58083.7500 60.3154
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 48 48.000000 2400.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 6.000000 300.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 158 156.500000 7825.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 16 506.000000 12650.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 923 7238.000000 361900.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1004 8300.000000 83000.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 69 342.181700 24445.4600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 25 71.500000 4089.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 85 368.000000 26289.9200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 31 231.250000 13218.2500 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 135 643.000000 45935.9200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 24 62.000000 3546.4000 57.2000
TRAV-TRAVS-Travel by mile 31 9597.000000 4270.7700 0.4450
Subtotal (Total Children Is Unduplicated) 1163 27573.43170 590217.5200 21.4053
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Total 32842.431700 806596.5200 24.5596
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Number of Children (Unduplicated) With at Least One Service 1701
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Center 57
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 2431 2486.750000 99109.7500 0.0000
P 264 224.613400 10659.5800 10659.6300
D 15 20.250000 805.7500 0.0000
S 96 80.250000 3392.8200 3393.8700
H 0 0.000000 0.0000 0.0000
T 3847 21160.250000 273226.2500 273224.4200
4285 8654.318300 414538.1600 317184.8300
Other 103 216.000000 4864.2100 4904.2100
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Total 11041 32842.431700 806596.5200 609366.9600