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: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 736 888.500000 32847.5000 36.9696
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 843 2839.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 244 726.500000 26843.5000 36.9491
Subtotal (Total Children Is Unduplicated) 1030 4454.500000 59691.0000 13.4002
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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 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 23.000000 1276.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 25.009333 1875.7000 75.0000
Subtotal (Total Children Is Unduplicated) 65 120.259333 7250.3200 60.2890
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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 831 6013.000000 60110.0000 9.9967
TRAV-TRAVS-Travel by mile 420 31231.00000 13894.8500 0.4449
Subtotal (Total Children Is Unduplicated) 831 38440.25000 134700.8700 3.5042
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Total 43015.009333 201642.1900 4.6877
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Number of Children (Unduplicated) With at Least One Service 1100
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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 2004 13227.750000 23720.8300 23720.8300
T 0 0.000000 0.0000 0.0000
14434 29777.259333 177821.3600 0.0000
Other 10 10.000000 100.0000 0.0000
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Total 16448 43015.009333 201642.1900 23720.8300