CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 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 736 888.500000 32847.5000 36.9696
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 843 2845.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1009 3214.000000 118427.7500 36.8475
Subtotal (Total Children Is Unduplicated) 1130 6947.750000 151275.2500 21.7733
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 26.2500 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 16.1200 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 65.5200 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 22.9000 22.9000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 25.5300 25.5300
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 46.8000 46.8000
EXIT-EXIT-EXIT ASSESSMENT 8 10.250000 512.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 42.500000 3037.5000 71.4706
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 40.500000 3037.5000 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 13 20.500000 1537.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 41 82.500000 4578.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 46.500000 3487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 25.500000 1912.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 33.000000 2475.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 171 311.000000 17260.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 198 352.000000 26400.0000 75.0000
Subtotal (Total Children Is Unduplicated) 295 976.750000 64554.8700 66.0915
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 1364.7700 341.1925
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 73 84.500000 4225.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.250000 6.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 321 840.000000 42000.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 21 11.000000 275.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 4 8.000000 400.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 20 55.000000 4032.6000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 22.000000 550.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 657 3521.750000 176125.0000 50.0106
INTR-T1013-INTERPRETER 1 2.000000 200.0000 100.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 831 6021.000000 60190.0000 9.9967
TRAV-TRAVS-Travel by mile 420 31231.00000 13894.8500 0.4449
Subtotal (Total Children Is Unduplicated) 831 41801.50000 303313.4700 7.2560
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Total 49726.000000 519143.5900 10.4401
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Number of Children (Unduplicated) With at Least One Service 1156
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Center 53
Flag Claims Units Chgs Paid
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R 3 4.250000 194.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1975 1860.750000 85741.7900 0.0000
P 2057 1940.000000 86268.7500 86218.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2004 13227.750000 23720.8300 23720.8300
T 1 1.000000 37.0000 0.0000
17159 32682.250000 323080.9700 0.0000
Other 10 10.000000 100.0000 0.0000
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Total 23209 49726.000000 519143.5900 109939.5800