CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 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 836 1167.500000 43142.0000 36.9525
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 930 2928.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1118 3360.000000 124025.0000 36.9122
Subtotal (Total Children Is Unduplicated) 1254 7455.500000 167167.0000 22.4220
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 12.6100 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 16.5200 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 75.9300 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 18.5500 18.5500
EVAL-96111-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 12 16.250000 812.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 47.000000 3525.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 35 93.000000 6975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 24.500000 1800.0000 73.4694
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 46 98.500000 5466.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 58.500000 4387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 24.500000 1837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 36.500000 2737.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 176 301.000000 16694.5000 55.4635
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 214 396.500821 29737.5123 74.9999
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
Subtotal (Total Children Is Unduplicated) 321 1109.250821 74321.4323 67.0015
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 87 93.500000 4637.5000 49.5989
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 1.750000 43.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 330 773.000000 38618.5000 49.9592
CONIP-CONIP-CONSULT, ITDS PHONE 41 18.500000 462.5000 25.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 12 32.000000 2346.2400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 16 52.500000 1312.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 732 4239.000000 211887.5000 49.9853
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 882 6803.500000 68005.0000 9.9956
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 50.0000 50.0000
TRAV-TRAVS-Travel by mile 457 43436.00000 19332.0100 0.4451
Subtotal (Total Children Is Unduplicated) 882 55453.75000 346788.5000 6.2537
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Total 64018.500821 588276.9323 9.1892
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Number of Children (Unduplicated) With at Least One Service 1287
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Center 53
Flag Claims Units Chgs Paid
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R 3 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 460 384.500000 16606.5000 1470.7500
P 4180 4052.950000 183187.2500 182337.5000
D 10 12.000000 661.0000 0.0000
S 3 2.500000 118.5000 18.5000
H 0 0.000000 0.0000 0.0000
T 6059 46809.651622 69404.1267 69404.1300
15643 12725.649199 316738.0556 0.0000
Other 33 29.750000 1506.0000 0.0000
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Total 26391 64018.500821 588276.9323 253230.8800