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: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 711 907.750000 33512.7500 36.9185
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 769 2625.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 913 2812.250000 103720.2500 36.8816
Subtotal (Total Children Is Unduplicated) 1090 6345.750000 137233.0000 21.6260
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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 19 36.000000 2700.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 38 87.000000 4828.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 41.500000 3112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 30.500000 2287.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 155 265.500000 14735.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 186 325.500000 24487.5000 75.2304
Subtotal (Total Children Is Unduplicated) 265 936.000000 62014.4300 66.2547
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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 792 5586.000000 55840.0000 9.9964
TRAV-TRAVS-Travel by mile 363 29870.00000 13286.6200 0.4448
Subtotal (Total Children Is Unduplicated) 792 39836.25000 287955.2900 7.2285
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Total 47118.000000 487202.7200 10.3401
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Number of Children (Unduplicated) With at Least One Service 1119
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Center 53
Flag Claims Units Chgs Paid
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R 6 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 554 535.750000 26091.0000 0.0000
P 2931 2805.000000 125711.0000 125711.0000
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 1867 13560.500000 23203.6000 23203.6000
16275 30195.500000 311155.6200 0.0000
Other 18 17.000000 884.2500 0.0000
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Total 21651 47118.000000 487202.7200 148914.6000