CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2016 ending 06/30/2017 Date of Report:08/05/2017 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 171 267.500000 9897.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 217 592.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 222 1224.250000 45103.0000 36.8413
Subtotal (Total Children Is Unduplicated) 224 2083.750000 55000.5000 26.3950
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 8.7500 8.7500
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.8400 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 22.9000 22.9000
EVAL-96111-DEVELOPMENTAL EVALUATION 3 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 25.500000 1912.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 32.000000 1776.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 37.500000 2812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.000000 675.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 148 228.000000 12654.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 168 272.500000 20512.5000 75.2752
Subtotal (Total Children Is Unduplicated) 208 635.000000 42308.4900 66.6275
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 7.250000 362.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 31.000000 1550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 209 462.000000 4620.0000 10.0000
TRAV-TRAVS-Travel by mile 61 1073.000000 477.6500 0.4452
Subtotal (Total Children Is Unduplicated) 209 1574.250000 7060.1500 4.4848
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Total 4293.000000 104369.1400 24.3115
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Number of Children (Unduplicated) With at Least One Service 224
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Center 53
Flag Claims Units Chgs Paid
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R 8 7.250000 268.2500 129.5000
U 0 0.000000 0.0000 0.0000
B 89 92.000000 4570.0000 453.2500
P 917 1029.000000 47183.7500 47071.2500
D 0 0.000000 0.0000 0.0000
S 63 67.250000 2460.5000 2405.0000
H 46 318.000000 696.2400 696.2400
T 125 865.750000 2190.9000 2190.9000
2223 1909.750000 46756.2500 3607.5000
Other 3 4.000000 243.2500 0.0000
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Total 3474 4293.000000 104369.1400 56553.6400