CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 677 542.250000 20063.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1023 3177.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1394 4145.750000 153244.7500 36.9643
Subtotal (Total Children Is Unduplicated) 1468 7865.250000 173308.0000 22.0346
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 5 6.000000 291.0000 48.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 17.5000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 8.0600 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 43.6800 21.8400
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 46.8000 46.8000
EXIT-EXIT-EXIT ASSESSMENT 23 45.500000 2275.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 33.000000 2475.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 21.000000 1575.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 24.500000 1837.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 39.000000 2164.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 176 292.000000 21862.5000 74.8716
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 95 147.000000 11025.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 31.000000 2325.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 211 350.500000 19397.2500 55.3417
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 93 152.000000 11400.0000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 407 1165.500000 77846.9400 66.7927
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 17 56.000000 8864.7600 158.2993
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 74 37.250000 1862.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 558 865.250000 43262.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 19 7.000000 149.2500 21.3214
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 11.000000 550.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 2.000000 50.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 58.000000 2900.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 822 4460.000000 222960.0000 49.9910
INTR-T1013-INTERPRETER 33 115.500000 2887.5000 25.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1113 8019.000000 80180.0000 9.9988
OCCT-97530-OT SESSION BY LICENSED OT 13 56.000000 4000.6400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 23 106.000000 7572.6400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 135.750000 9697.9800 71.4400
TRAV-TRAVS-Travel by mile 699 52391.00000 23321.3100 0.4451
Subtotal (Total Children Is Unduplicated) 1114 66319.75000 408259.0800 6.1559
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Total 75350.500000 659414.0200 8.7513
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Number of Children (Unduplicated) With at Least One Service 1480
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Center 54
Flag Claims Units Chgs Paid
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R 3 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5199 4305.500000 185784.0000 50.0000
P 722 746.000000 39899.5000 39915.2500
D 0 0.000000 0.0000 0.0000
S 4 3.250000 47.9000 0.0000
H 3530 22840.980000 54111.5600 54111.5600
T 4256 25952.750000 58120.1800 58120.1800
17025 21497.270000 321275.1300 92809.7300
Other 4 2.750000 101.7500 0.0000
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Total 30743 75350.500000 659414.0200 245006.7200