CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2015 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 1641 3918.500000 144200.5000 36.7999
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1558 8928.000000 804.7500 0.0901
TCM-T1017TL-TARGETED CASE MANAGEMENT 1892 10425.00000 383449.5000 36.7817
Subtotal (Total Children Is Unduplicated) 1988 23271.50000 528454.7500 22.7082
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 5 7.000000 339.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 14.9300 14.9300
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 8.000000 83.3600 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 10.000000 87.5000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 7 9.000000 72.5400 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 12 14.000000 305.7600 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 9 9.000000 206.1000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 41 61.750000 3087.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 77 207.000000 15525.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 73 191.500000 14362.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 35 62.500000 4762.5000 76.2000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 132 290.000000 16039.5000 55.3086
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 115 215.000000 16087.5000 74.8256
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 57 101.500000 7612.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 40.000000 3000.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 622 1069.000000 59662.5000 55.8115
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 703 1235.000100 93712.5075 75.8806
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 969 3534.750100 235200.2475 66.5394
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 11.000000 11020.4100 1001.8555
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 256 349.250000 17468.7500 50.0179
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 14 9.000000 225.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 648 2936.000000 148591.2500 50.6101
CONIP-CONIP-CONSULT, ITDS PHONE 150 68.500000 1737.5000 25.3650
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 16 52.000000 3812.6400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 32 100.000000 2500.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1048 15774.25000 788687.5000 49.9984
INTR-T1013-INTERPRETER 1 4.000000 280.0000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1353 24142.00000 240550.5000 9.9640
TRAV-A0160-*PROV TRAVEL TO NATURAL ENV-BY MIN 317 33532.00000 16782.5000 0.5005
TRAV-TRAVS-Travel by mile 849 156115.0000 69476.4320 0.4450
Subtotal (Total Children Is Unduplicated) 1404 233107.2500 1301844.9820 5.5847
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Total 259913.500100 2065499.9795 7.9469
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Number of Children (Unduplicated) With at Least One Service 2052
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Center 53
Flag Claims Units Chgs Paid
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R 356 291.000000 10718.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3799 3752.250000 169335.7500 3172.7500
P 10055 9430.500000 421038.2500 420716.8300
D 0 0.000000 0.0000 0.0000
S 3 4.000000 101.7500 0.0000
H 17686 126657.160267 221897.2370 221890.5670
T 16241 80369.750000 206041.1950 205944.6800
43133 35902.339833 1027817.7975 680.5000
Other 246 235.500000 5622.5000 0.0000
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Total 91519 256642.500100 2062572.4795 852405.3270