CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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 784 1011.500000 37342.2500 36.9177
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 766 1791.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 197 538.500000 19850.5000 36.8626
Subtotal (Total Children Is Unduplicated) 1058 3341.750000 57192.7500 17.1146
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 6.000000 291.0000 48.5000
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 21.5500 21.5500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 33.0400 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 18.1200 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 75.9300 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 37.1000 18.5500
EXIT-EXIT-EXIT ASSESSMENT 11 10.750000 537.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.490223 36.7667 74.9999
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 24.000000 1332.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 24.500000 1837.5000 75.0000
Subtotal (Total Children Is Unduplicated) 46 101.240223 5924.5067 58.5193
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 56.5000 56.5000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 68 85.000000 4250.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 310 752.250000 37600.0000 49.9834
CONIP-CONIP-CONSULT, ITDS PHONE 9 4.250000 106.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 5.000000 366.6000 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 300 650.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 40 121.750000 6087.5000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 140.0000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 844 5974.000000 59730.0000 9.9983
TRAV-TRAVS-Travel by mile 480 38761.00000 17236.9300 0.4447
Subtotal (Total Children Is Unduplicated) 845 46360.50000 125711.2800 2.7116
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Total 49803.490223 188828.5367 3.7915
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Number of Children (Unduplicated) With at Least One Service 1131
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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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1870 15118.500000 20486.9400 20486.9400
T 1525 10529.740223 17180.8367 17158.3400
12658 24155.250000 151160.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16053 49803.490223 188828.5367 37645.2800