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: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 1983 4257.750000 157310.2500 36.9468
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1864 11292.75000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2328 12825.00000 473191.6900 36.8960
Subtotal (Total Children Is Unduplicated) 2470 28375.50000 630501.9400 22.2199
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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) 19 20.000000 170.1000 8.5050
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 11 11.000000 94.6600 8.6055
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 21 22.000000 518.6500 23.5750
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 12 12.000000 248.3900 20.6992
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 7 12.000000 600.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 52 68.250000 3412.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 62 159.000000 11775.0000 74.0566
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 98 279.500000 20887.5000 74.7317
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 72 128.000000 9562.5000 74.7070
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 195 434.500000 24023.7500 55.2906
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 105 170.500000 12787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 62 111.500000 8362.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 66 103.000000 7725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 699 1205.000000 66811.0000 55.4448
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 795 1413.000952 106050.0221 75.0530
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) 1094 4169.750952 273658.7721 65.6295
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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 267 331.000000 16512.5000 49.8867
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 12 5.750000 143.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 778 3291.000000 164418.5000 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 1220 17357.00000 867718.5000 49.9924
INTR-T1013-INTERPRETER 1 2.000000 200.0000 100.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1573 27491.50000 274845.0000 9.9975
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 944 182139.0000 81047.0000 0.4450
Subtotal (Total Children Is Unduplicated) 1573 231035.0000 1428990.5300 6.1852
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Total 263580.250952 2333151.2421 8.8518
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Number of Children (Unduplicated) With at Least One Service 2472
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Center 53
Flag Claims Units Chgs Paid
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R 30 29.250000 1228.7500 721.5000
U 0 0.000000 0.0000 0.0000
B 1029 944.500000 42270.5000 6456.5000
P 16916 16140.205000 731862.1000 714697.5000
D 60 63.750000 3330.0700 0.0000
S 888 842.750000 30983.4400 30772.4400
H 7971 54199.171400 100961.2900 100961.2900
T 17905 142805.188519 224072.1640 224072.1700
59894 48472.186033 1194556.4281 47411.0000
Other 85 83.250000 3886.5000 0.0000
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Total 104778 263580.250952 2333151.2421 1125092.4000