CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2016 ending 06/30/2017 Date of Report:08/05/2017 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1811 3989.750000 147394.2500 36.9432
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1647 10700.75000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2105 11599.75000 428051.6900 36.9018
Subtotal (Total Children Is Unduplicated) 2245 26290.25000 575445.9400 21.8882
-----------------------------------------------------------------------------------------------------------------------
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) 9 10.000000 117.3400 11.7340
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 21.5500 21.5500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 18 19.000000 161.3500 8.4921
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 11 11.000000 94.6600 8.6055
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 20 21.000000 496.8100 23.6576
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 11 11.000000 225.4900 20.4991
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
EVAL-96111-DEVELOPMENTAL EVALUATION 4 6.000000 300.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 52 68.250000 3412.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 60 155.000000 11475.0000 74.0323
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 97 278.000000 20775.0000 74.7302
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 56 102.500000 7650.0000 74.6341
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 175 402.500000 22247.7500 55.2739
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 79 133.000000 9975.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 56 102.500000 7687.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 55 87.000000 6525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 551 977.000000 54157.0000 55.4319
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 627 1140.500952 85537.5221 75.0000
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
WHEELO-97003TG-WHEELCHAIR EVAL/ FITTING BY LICENSED O 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 886 3534.750952 231350.2821 65.4502
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 8.000000 4171.1300 521.3913
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 266 330.000000 16462.5000 49.8864
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 12 5.750000 143.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 776 3283.750000 164056.0000 49.9600
CONIP-CONIP-CONSULT, ITDS PHONE 134 85.250000 2131.2500 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
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 31 195.000000 14297.4000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 34 116.500000 2912.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1218 17326.00000 866168.5000 49.9924
INTR-T1013-INTERPRETER 1 2.000000 200.0000 100.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1364 27029.50000 270225.0000 9.9974
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 883 181066.0000 80569.3500 0.4450
Subtotal (Total Children Is Unduplicated) 1364 229460.7500 1421930.3800 6.1968
-----------------------------------------------------------------------------------------------------------------------
Total 259285.750952 2228726.6021 8.5956
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2247
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 22 22.000000 960.5000 592.0000
U 0 0.000000 0.0000 0.0000
B 940 852.500000 37700.5000 6003.2500
P 15999 15111.205000 684678.3500 667626.2500
D 60 63.750000 3330.0700 0.0000
S 825 775.500000 28522.9400 28367.4400
H 7925 53881.171400 100265.0500 100265.0500
T 17780 141939.438519 221881.2640 221881.2700
57667 46560.936033 1147744.6781 43766.5000
Other 82 79.250000 3643.2500 0.0000
---------------------------------------------------------
Total 101300 259285.750952 2228726.6021 1068501.7600