CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2016 ending 06/30/2016 Date of Report:08/06/2016 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 760 1083.500000 40024.7500 36.9402
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 735 2622.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 215 520.750000 19156.7500 36.7868
Subtotal (Total Children Is Unduplicated) 969 4226.750000 59181.5000 14.0017
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 10.4200 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 17.5000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 16.1200 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.8400 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 45.8000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 11 17.500000 875.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 16.000000 1200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 14.000000 1050.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 22.500000 1248.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 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 10 18.000000 999.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 23.500000 1762.5000 75.0000
Subtotal (Total Children Is Unduplicated) 61 128.500000 7921.9300 61.6493
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 103 107.000000 5325.0000 49.7664
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.250000 31.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 335 1085.750000 54222.5000 49.9401
CONIP-CONIP-CONSULT, ITDS PHONE 43 18.750000 468.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.250000 12.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 14.000000 700.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 7.000000 513.2400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 10.000000 250.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 65 276.000000 13800.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 751 7867.000000 78670.0000 10.0000
TRAV-TRAVS-Travel by mile 469 51182.00000 22782.6600 0.4451
Subtotal (Total Children Is Unduplicated) 751 60569.00000 176775.9000 2.9186
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Total 64924.250000 243879.3300 3.7564
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Number of Children (Unduplicated) With at Least One Service 1036
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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 2 1.750000 10.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8241 55897.500000 97408.6700 97402.0000
T 3783 2906.500000 45486.0300 45476.0300
8073 6118.500000 100974.6300 130.5000
Other 0 0.000000 0.0000 0.0000
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Total 20099 64924.250000 243879.3300 143008.5300