CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
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 677 867.000000 32014.2500 36.9253
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 715 2492.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 856 2537.000000 93619.2500 36.9016
Subtotal (Total Children Is Unduplicated) 1033 5896.000000 125633.5000 21.3083
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 20.8400 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 35.0000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 24.1800 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 87.3600 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 45.8000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 13 16.000000 800.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 17 48.000000 3600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 21 58.000000 4275.0000 73.7069
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 29.500000 2212.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 33 78.000000 4329.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 36.500000 2737.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 25.500000 1912.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 122 212.500000 11793.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 148 266.500000 20025.0000 75.1407
Subtotal (Total Children Is Unduplicated) 220 795.500000 52648.4300 66.1828
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 19.6000 19.6000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 65 58.750000 2937.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 307 749.250000 37425.0000 49.9499
CONIP-CONIP-CONSULT, ITDS PHONE 51 31.750000 793.7500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 18 51.000000 3739.3200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 17.000000 425.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 631 3470.500000 173463.5000 49.9823
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 747 5497.000000 54950.0000 9.9964
TRAV-TRAVS-Travel by mile 352 29675.00000 13199.8300 0.4448
Subtotal (Total Children Is Unduplicated) 747 39552.25000 286978.5000 7.2557
-----------------------------------------------------------------------------------------------------------------------
Total 46243.750000 465260.4300 10.0610
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1062
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 550 529.750000 25699.5000 0.0000
P 2814 2660.500000 119138.5000 119138.5000
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 1854 13454.500000 22875.4300 22875.4300
15730 29579.250000 296618.0000 0.0000
Other 17 15.500000 771.7500 0.0000
---------------------------------------------------------
Total 20971 46243.750000 465260.4300 142013.9300