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: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 1641 3915.250000 144080.2500 36.7998
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1558 8920.000000 804.7500 0.0902
TCM-T1017TL-TARGETED CASE MANAGEMENT 520 2032.500000 74841.7500 36.8225
Subtotal (Total Children Is Unduplicated) 1913 14867.75000 219726.7500 14.7787
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 5 7.000000 339.5000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 7.000000 72.9400 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 8.000000 70.0000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 6 7.000000 56.4200 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 10 11.000000 240.2400 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 8 8.000000 183.2000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 39 59.750000 2987.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 50 56.000000 4200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 47 55.000000 4125.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 49 63.500000 3524.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 26.500000 1987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 100.190800 5532.8394 55.2230
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 87 150.970667 11435.3000 75.7452
Subtotal (Total Children Is Unduplicated) 263 580.411467 36292.1894 62.5284
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 11.000000 11020.4100 1001.8555
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 255 341.750000 17093.7500 50.0183
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 14 9.000000 225.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 648 2935.000000 148541.2500 50.6103
CONIP-CONIP-CONSULT, ITDS PHONE 150 68.500000 1737.5000 25.3650
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 6 20.000000 1466.4000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 30.000000 750.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 170 1127.033600 56026.6800 49.7116
INTR-T1013-INTERPRETER 1 4.000000 280.0000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1353 24126.00000 240390.5000 9.9640
TRAV-A0160-*PROV TRAVEL TO NATURAL ENV-BY MIN 317 33532.00000 16782.5000 0.5005
TRAV-TRAVS-Travel by mile 849 156055.0000 69449.7220 0.4450
Subtotal (Total Children Is Unduplicated) 1401 218273.5336 564476.2120 2.5861
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Total 233721.695067 820495.1514 3.5106
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Number of Children (Unduplicated) With at Least One Service 1993
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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 4 3.750000 30.0000 55.5800
D 0 0.000000 0.0000 0.0000
S 1 1.250000 0.0000 0.0000
H 17686 126657.160267 221897.2370 221890.5670
T 16240 80368.750000 205991.1950 205944.6800
30902 23228.284800 386276.7194 130.5000
Other 228 216.500000 4622.5000 0.0000
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Total 65061 230475.695067 818817.6514 428021.3270