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
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 711 907.750000 33512.7500 36.9185
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 769 2620.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 220 686.500000 25354.2500 36.9326
Subtotal (Total Children Is Unduplicated) 1009 4214.500000 58867.0000 13.9677
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 10.4200 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 17.5000 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) 2 2.000000 45.8000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 12 15.000000 750.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 14.000000 1050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 18.000000 1275.0000 70.8333
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 27.000000 1498.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 46.000000 2553.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 55.000000 4125.0000 75.0000
Subtotal (Total Children Is Unduplicated) 80 196.500000 12269.3600 62.4395
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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 307 748.250000 37375.0000 49.9499
CONIP-CONIP-CONSULT, ITDS PHONE 51 31.750000 793.7500 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 14 41.000000 3006.1200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 47 195.000000 9750.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 792 5576.000000 55740.0000 9.9964
TRAV-TRAVS-Travel by mile 363 29870.00000 13286.6200 0.4448
Subtotal (Total Children Is Unduplicated) 792 36525.75000 123008.5900 3.3677
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Total 40936.750000 194144.9500 4.7426
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Number of Children (Unduplicated) With at Least One Service 1075
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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 0 0.000000 0.0000 0.0000
T 1867 13560.500000 23203.6000 23203.6000
13623 27376.250000 170941.3500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15490 40936.750000 194144.9500 23203.6000