CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2015 ending 06/30/2016 Date of Report:08/07/2016 Page: 1
List order: No List
Payclass Filters:TPIN
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 4 3.250000 120.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 7.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 45 176.750000 6530.5000 36.9477
Subtotal (Total Children Is Unduplicated) 50 187.000000 6650.7500 35.5655
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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) 1 1.000000 10.4200 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 2.000000 17.5000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 2.000000 16.1200 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 3.000000 65.5200 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 22.9000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 31.000000 2325.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 26.000000 1950.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 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 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 24.000000 1800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 68 123.000000 6826.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 67 119.373333 9065.5000 75.9424
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 111 356.373333 23619.1900 66.2765
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 6 7.500000 375.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 7.000000 513.2400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 7.000000 175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 163 1825.716400 91748.3200 50.2533
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 13 15.000000 150.0000 10.0000
TRAV-TRAVS-Travel by mile 2 60.000000 26.7100 0.4452
Subtotal (Total Children Is Unduplicated) 163 1923.216400 93038.2700 48.3764
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Total 2466.589733 123308.2100 49.9914
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Number of Children (Unduplicated) With at Least One Service 210
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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 10 10.000000 500.0000 236.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.000000 50.0000 0.0000
2207 2438.589733 121858.2100 150.0000
Other 16 17.000000 900.0000 0.0000
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Total 2234 2466.589733 123308.2100 386.2500