CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 911 1188.500000 43913.7500 36.9489
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 886 2712.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1083 3303.500000 121995.9400 36.9293
Subtotal (Total Children Is Unduplicated) 1231 7204.750000 165909.6900 23.0278
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 73.4700 12.2450
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 49.5600 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 4 4.000000 36.2400 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 148.3900 24.7317
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 78.2400 19.5600
EVAL-96111-DEVELOPMENTAL EVALUATION 6 10.000000 500.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 14 18.500000 925.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 22.000000 1650.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 25 74.000000 5550.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 44.000000 3300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 48 103.000000 5716.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 24.000000 1800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 31.000000 2325.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 17.500000 1312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 158 261.000000 14430.0000 55.2874
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 202 346.500031 25987.5023 75.0000
Subtotal (Total Children Is Unduplicated) 308 979.000031 63994.9023 65.3676
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 2191.7600 1095.8800
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 81 78.000000 3900.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 5 2.750000 68.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 320 742.750000 37075.0000 49.9159
CONIP-CONIP-CONSULT, ITDS PHONE 34 22.000000 550.0000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 15 49.000000 3592.6800 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 10 25.000000 625.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 612 3425.500000 171230.0000 49.9869
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 806 5815.000000 58120.0000 9.9948
TRAV-TRAVS-Travel by mile 376 33212.00000 14758.0900 0.4444
Subtotal (Total Children Is Unduplicated) 806 43374.00000 292111.2800 6.7347
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Total 51557.750031 522015.8723 10.1249
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Number of Children (Unduplicated) With at Least One Service 1251
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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 133 137.250000 6642.2500 0.0000
P 4103 3857.675000 173491.1400 172529.5000
D 3 3.000000 150.0000 0.0000
S 476 344.500000 12679.4400 12623.9400
H 0 0.000000 0.0000 0.0000
T 3359 27487.447431 42887.6823 42887.6800
15807 19710.627600 285306.1100 19151.5000
Other 18 17.250000 859.2500 0.0000
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Total 23899 51557.750031 522015.8723 247192.6200