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
Payclass Filters:GR
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 4257.500000 157301.0000 36.9468
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1864 11280.25000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 639 2858.750000 105487.0000 36.8997
Subtotal (Total Children Is Unduplicated) 2369 18396.50000 262788.0000 14.2847
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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) 7 8.000000 94.3100 11.7888
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 21.5500 21.5500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 14 14.000000 119.5600 8.5400
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 8 8.000000 68.4800 8.5600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 14 14.000000 319.6400 22.8314
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 9 9.000000 192.7400 21.4156
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 6 10.000000 500.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 50 66.250000 3312.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 39 43.000000 3075.0000 71.5116
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 77 94.000000 6975.0000 74.2021
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 64 83.500000 4634.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 13.500000 1012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 11.333333 850.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 18.000000 1350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 61 106.000000 5883.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 73 120.259386 9019.4540 75.0000
Subtotal (Total Children Is Unduplicated) 263 632.342719 38227.7440 60.4542
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 8.000000 4171.1300 521.3913
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 3290.000000 164368.5000 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 30 170.000000 12464.4000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 25.500000 637.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 169 1445.404000 72270.2000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 200.0000 100.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1573 27480.50000 274735.0000 9.9975
TRAV-TRAVS-Travel by mile 944 182139.0000 81047.0000 0.4450
Subtotal (Total Children Is Unduplicated) 1573 214992.4040 629156.2300 2.9264
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Total 234021.246719 930171.9740 3.9747
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Number of Children (Unduplicated) With at Least One Service 2395
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 288 303.500000 15962.3500 0.0000
D 36 36.000000 1823.3200 0.0000
S 0 0.000000 0.0000 0.0000
H 7940 54168.618200 99433.6300 99433.6300
T 17764 142659.683519 216779.4940 216779.5000
48689 36842.445000 596063.1800 43914.2500
Other 11 11.000000 110.0000 0.0000
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Total 74728 234021.246719 930171.9740 360127.3800