CMS/EIP Fiscal Report Center: 54
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 677 542.250000 20063.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1023 3176.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 346 894.250000 33031.7500 36.9379
Subtotal (Total Children Is Unduplicated) 1260 4612.750000 53095.0000 11.5105
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 5 6.000000 291.0000 48.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 17.5000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 8.0600 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 43.6800 21.8400
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 46.8000 46.8000
EXIT-EXIT-EXIT ASSESSMENT 22 43.500000 2175.0000 50.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 43.000000 3225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 74.500000 4134.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 33.000000 2475.0000 75.0000
Subtotal (Total Children Is Unduplicated) 95 235.500000 14609.7900 62.0373
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 17 48.640000 8100.3900 166.5376
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 74 37.250000 1862.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 558 864.000000 43200.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 19 7.000000 149.2500 21.3214
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 11.000000 550.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 58.000000 2900.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 154 772.750000 38637.5000 50.0000
INTR-T1013-INTERPRETER 33 115.500000 2887.5000 25.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1113 8019.000000 80180.0000 9.9988
OCCT-97530-OT SESSION BY LICENSED OT 6 16.000000 1143.0400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 14 49.050000 3500.2500 71.3609
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 117.750000 8412.0600 71.4400
TRAV-TRAVS-Travel by mile 685 51571.00000 22956.2900 0.4451
Subtotal (Total Children Is Unduplicated) 1113 61686.94000 214478.7800 3.4769
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Total 66535.190000 282183.5700 4.2411
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Number of Children (Unduplicated) With at Least One Service 1350
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Center 54
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 3 3.000000 38.6500 0.0000
H 3530 22840.980000 54111.5600 54111.5600
T 4256 25952.750000 58120.1800 58120.1800
14061 17738.460000 169913.1800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 21850 66535.190000 282183.5700 112231.7400