CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 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 689 839.000000 31016.0000 36.9678
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 783 2629.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 225 661.000000 24420.0000 36.9440
Subtotal (Total Children Is Unduplicated) 967 4129.250000 55436.0000 13.4252
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 26.2500 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 16.1200 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 65.5200 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 22.9000 22.9000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 25.5300 25.5300
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 46.8000 46.8000
EXIT-EXIT-EXIT ASSESSMENT 8 10.250000 512.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 13.000000 825.0000 63.4615
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 13.000000 975.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 19.000000 1054.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 21.509333 1613.2000 75.0000
Subtotal (Total Children Is Unduplicated) 60 111.759333 6690.8200 59.8681
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 1364.7700 341.1925
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 72 83.500000 4175.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.250000 6.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 321 838.250000 41912.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 21 11.000000 275.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 4 8.000000 400.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 63 244.250000 12212.5000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 200.0000 100.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 776 5909.000000 59070.0000 9.9966
TRAV-TRAVS-Travel by mile 406 31024.00000 13802.6900 0.4449
Subtotal (Total Children Is Unduplicated) 776 38129.25000 133568.7100 3.5031
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Total 42370.259333 195695.5300 4.6187
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Number of Children (Unduplicated) With at Least One Service 1037
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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 0 0.000000 0.0000 0.0000
H 1993 13181.750000 23633.4600 23633.4600
T 0 0.000000 0.0000 0.0000
13987 29179.509333 171972.0700 0.0000
Other 9 9.000000 90.0000 0.0000
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Total 15989 42370.259333 195695.5300 23633.4600