CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2016 ending 06/30/2016 Date of Report:08/07/2016 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 816 1139.250000 42087.5000 36.9432
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 814 2873.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1004 3239.500000 119362.0000 36.8458
Subtotal (Total Children Is Unduplicated) 1137 7252.500000 161449.5000 22.2612
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 14.9300 14.9300
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 20.8400 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 4.000000 35.0000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 4.000000 32.2400 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 4.000000 87.3600 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 68.7000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 12 18.500000 925.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 60.000000 4500.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 46.500000 3487.5000 75.0000
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 11 18.000000 1350.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 40 87.000000 4828.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 32.000000 2400.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 33.000000 2475.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 20.000000 1500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 186 317.000000 17593.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 194 336.000000 25200.0000 75.0000
Subtotal (Total Children Is Unduplicated) 295 987.500000 64631.0700 65.4492
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 105 113.500000 5650.0000 49.7797
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.250000 31.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 335 1086.750000 54272.5000 49.9402
CONIP-CONIP-CONSULT, ITDS PHONE 43 18.750000 468.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.250000 12.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 14.000000 700.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 14 37.000000 2712.8400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 51.000000 1275.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 681 4764.250000 238187.5000 49.9948
INTR-T1013-INTERPRETER 1 2.000000 140.0000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 822 8009.000000 80090.0000 10.0000
TRAV-TRAVS-Travel by mile 492 51909.00000 23106.2500 0.4451
Subtotal (Total Children Is Unduplicated) 822 66006.75000 406646.5900 6.1607
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Total 74246.750000 632727.1600 8.5220
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Number of Children (Unduplicated) With at Least One Service 1170
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Center 53
Flag Claims Units Chgs Paid
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R 164 148.500000 5454.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1577 1577.250000 75902.5000 0.0000
P 2169 1928.250000 80555.5000 80508.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8317 56627.500000 99392.7300 99386.0600
T 3969 3074.500000 48511.5300 48451.5300
12747 10888.750000 322810.1500 330.5000
Other 2 2.000000 100.0000 0.0000
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Total 28945 74246.750000 632727.1600 228676.5900