CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.250000 9.2500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 10.4200 10.4200
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-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 239.2000 119.6000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.500000 862.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 19 31.500000 2004.2600 63.6273
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 54 62.750000 3137.5000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 116 195.250000 9762.5000 50.0000
CONIP-CONIP-CONSULT, PHONE 8 7.000000 175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 48 275.500000 13775.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 364 2454.000000 24540.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 31 138.000000 9800.2400 71.0162
OCCT-97530HM-OT SESSION BY OT ASST 14 83.500000 4733.4800 56.6884
PHY-97110-PT SESSION BY LICENSED PT 15 124.500000 8635.7200 69.3632
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 111 639.000000 43238.7300 67.6662
TRAV-TRAVS-Travel by mile 252 19018.00000 8463.6200 0.4450
Subtotal (Total Children Is Unduplicated) 391 22999.50000 126297.7900 5.4913
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Total 23031.250000 128311.3000 5.5712
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Number of Children (Unduplicated) With at Least One Service 393
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Center 52
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 0.750000 53.5800 53.5800
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 2548 23012.500000 128054.7300 126901.1600
8 18.000000 202.9900 56.2400
Other 0 0.000000 0.0000 0.0000
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Total 2557 23031.250000 128311.3000 127010.9800