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
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 742 1111.500000 40545.0000 36.4777
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 705 2349.000000 786.2500 0.3347
TCM-T1017TL-TARGETED CASE MANAGEMENT 183 446.250000 16437.2500 36.8342
Subtotal (Total Children Is Unduplicated) 924 3906.750000 57768.5000 14.7868
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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) 1 1.000000 10.4200 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 14 20.250000 1012.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 17.000000 1275.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 19.000000 1054.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 21.000000 1165.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 51.500000 3862.5000 75.0000
Subtotal (Total Children Is Unduplicated) 77 162.250000 10554.4000 65.0502
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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 3 9.000000 225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 64 260.750000 13037.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 717 5590.000000 55833.0000 9.9880
TRAV-TRAVS-Travel by mile 377 37567.00000 16707.3200 0.4447
Subtotal (Total Children Is Unduplicated) 720 44185.25000 128081.5600 2.8987
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Total 48254.250000 196404.4600 4.0702
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Number of Children (Unduplicated) With at Least One Service 969
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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 0 0.000000 0.0000 0.0000
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
8844 22963.000000 112704.6400 0.0000
Other 127 121.250000 2557.5000 0.0000
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Total 15527 48254.250000 196404.4600 81142.3200