CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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 814 1182.750000 43632.2500 36.8905
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 811 2658.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 244 691.500000 25409.7500 36.7458
Subtotal (Total Children Is Unduplicated) 1012 4532.500000 69042.0000 15.2327
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 5.000000 242.5000 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 9 14.500000 725.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 18.000000 1350.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 24 26.000000 1950.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 18.000000 999.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 26.500000 1470.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 33.500000 2512.5000 75.0000
Subtotal (Total Children Is Unduplicated) 80 154.500000 9885.0700 63.9810
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 20.9800 20.9800
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 107 108.750000 5437.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 1.250000 31.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 293 712.750000 35625.0000 49.9825
CONIP-CONIP-CONSULT, ITDS PHONE 36 14.750000 368.7500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.000000 73.3200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 9.000000 225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 51 194.950000 9747.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 761 5373.000000 53720.0000 9.9981
TRAV-TRAVS-Travel by mile 380 24534.00000 10920.8500 0.4451
Subtotal (Total Children Is Unduplicated) 762 30950.45000 116170.1500 3.7534
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Total 35637.450000 195097.2200 5.4745
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Number of Children (Unduplicated) With at Least One Service 1049
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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 1 1.250000 0.0000 0.0000
H 1943 10442.950000 24410.8500 24410.8500
T 2147 13525.250000 24171.9700 24171.9700
11637 11572.750000 144449.4000 0.0000
Other 101 95.250000 2065.0000 0.0000
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Total 15829 35637.450000 195097.2200 48582.8200