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: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 4 3.250000 120.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 8.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 55 209.250000 7723.7500 36.9116
Subtotal (Total Children Is Unduplicated) 61 220.500000 7844.0000 35.5737
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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 3 5.000000 375.0000 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 21 36.000000 2662.5000 73.9583
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 97 168.309200 9341.1606 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 97 168.029433 12714.7075 75.6695
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 157 468.838633 31133.0581 66.4046
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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 165 1836.716400 92298.3200 50.2518
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14 16.000000 160.0000 10.0000
TRAV-TRAVS-Travel by mile 2 60.000000 26.7100 0.4452
Subtotal (Total Children Is Unduplicated) 166 1935.216400 93598.2700 48.3658
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Total 2624.555033 132575.3281 50.5134
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Number of Children (Unduplicated) With at Least One Service 261
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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
2319 2596.555033 131125.3281 150.0000
Other 16 17.000000 900.0000 0.0000
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Total 2346 2624.555033 132575.3281 386.2500