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
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 911 1188.500000 43913.7500 36.9489
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 886 2710.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 267 808.250000 29803.5000 36.8741
Subtotal (Total Children Is Unduplicated) 1151 4707.500000 73717.2500 15.6595
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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) 5 5.000000 41.3000 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 27.1800 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 97.7700 24.4425
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 59.6900 19.8967
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 6 9.000000 675.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 22 33.000000 2475.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 21.000000 1165.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 24.000000 1276.5000 53.1875
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 38.081231 2856.0923 75.0000
Subtotal (Total Children Is Unduplicated) 82 185.581231 10997.5023 59.2598
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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 10 41.000000 3006.1200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 64 247.941200 12397.0600 50.0000
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 40167.44120 132166.7800 3.2904
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Total 45060.522431 216881.5323 4.8131
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Number of Children (Unduplicated) With at Least One Service 1188
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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 27 27.000000 1396.6400 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 3355 27482.447431 42587.6823 42587.6800
13742 17551.075000 172897.2100 18514.0000
Other 0 0.000000 0.0000 0.0000
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Total 17124 45060.522431 216881.5323 61101.6800