CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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 742 1111.500000 40545.0000 36.4777
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 706 2352.250000 786.2500 0.3343
TCM-T1017TL-TARGETED CASE MANAGEMENT 892 2907.500000 106615.5000 36.6691
Subtotal (Total Children Is Unduplicated) 1011 6371.250000 147946.7500 23.2210
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 20.8400 10.4200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 43.6800 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 45.8000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 15 21.250000 1062.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 66.000000 4950.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 43.000000 3225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 17.500000 1312.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 36 78.000000 4329.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 62.500000 4687.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 24.000000 1800.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 142 247.000000 13653.0000 55.2753
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 173 323.500000 24262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 263 893.250000 59676.8200 66.8086
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.000000 4759.7200 1586.5733
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 99 94.500000 4725.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 6 5.000000 125.0000 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 251 631.000000 31512.5000 49.9406
CONIP-CONIP-CONSULT, PHONE 29 14.000000 350.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 11.000000 806.5200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 16.000000 400.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 598 3790.500000 189512.5000 49.9967
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 718 5600.000000 55933.0000 9.9880
TRAV-TRAVS-Travel by mile 377 37567.00000 16707.3200 0.4447
Subtotal (Total Children Is Unduplicated) 724 47732.00000 304831.5600 6.3863
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Total 54996.500000 512455.1300 9.3180
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Number of Children (Unduplicated) With at Least One Service 1031
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Center 53
Flag Claims Units Chgs Paid
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R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1845 1741.750000 72330.5000 0.0000
P 1726 1715.250000 80961.5000 81026.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1583 9828.000000 19566.5600 19566.5600
T 4973 15342.000000 61575.7600 61575.7600
12070 26247.750000 275444.8100 111.0000
Other 127 121.250000 2557.5000 0.0000
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Total 22325 54996.500000 512455.1300 162279.5700