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
Payclass Filters:GR
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 72 357.000000 13162.7500 36.8704
Subtotal (Total Children Is Unduplicated) 223 1216.500000 23060.2500 18.9562
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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 2 4.000000 200.0000 50.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 22.500000 1248.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 29.000000 2175.0000 75.0000
Subtotal (Total Children Is Unduplicated) 28 68.000000 4350.7400 63.9815
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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
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 1543.250000 5510.1500 3.5705
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Total 2827.750000 32921.1400 11.6422
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Number of Children (Unduplicated) With at Least One Service 223
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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 1 1.500000 112.5000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 46 318.000000 696.2400 696.2400
T 122 861.750000 1890.9000 1890.9000
2033 1645.500000 30211.5000 3382.5000
Other 1 1.000000 10.0000 0.0000
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Total 2203 2827.750000 32921.1400 5969.6400