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
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 413 231.750000 8574.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 395 2319.750000 99.0000 0.0427
TCM-T1017TL-TARGETED CASE MANAGEMENT 801 2134.250000 78634.2500 36.8440
Subtotal (Total Children Is Unduplicated) 855 4685.750000 87308.0000 18.6327
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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 2.000000 17.5000 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
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 172 349.000000 25345.0000 72.6218
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 76 154.000000 11380.0000 73.8961
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 76.000000 5700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 223 433.000000 23723.9800 54.7898
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 16 21.000000 1072.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 27 27.000000 1350.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 23 23.000000 1161.3800 50.4948
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 305 1116.000000 71733.9700 64.2778
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 109 132.250000 6612.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 177 444.000000 22181.2500 49.9578
CONIP-CONIP-CONSULT, PHONE 9 9.000000 222.0000 24.6667
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 311 1668.000000 83227.5000 49.8966
INTR-T1013-INTERPRETER 7 18.000000 900.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 587 4122.000000 41220.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 67 358.250000 25368.4400 70.8121
OCCT-97530HM-OT SESSION BY OT ASST 15 89.750000 5090.9800 56.7240
PHY-97110-PT SESSION BY LICENSED PT 30 232.750000 16181.1600 69.5216
PHY-97110HM-PT SESSION BY PT ASST 6 22.500000 1286.1000 57.1600
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 212 1271.500000 86437.0700 67.9804
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
TRAV-TRAVS-Travel by mile 584 41723.00000 18561.3150 0.4449
Subtotal (Total Children Is Unduplicated) 674 50098.00000 307404.8350 6.1361
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Total 55899.750000 466446.8050 8.3443
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Number of Children (Unduplicated) With at Least One Service 964
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Center 52
Flag Claims Units Chgs Paid
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R 28 52.500000 3918.5000 1050.0000
U 0 0.000000 0.0000 0.0000
B 1826 1802.500000 89044.2500 15060.0000
P 911 772.000000 28335.7800 28333.2800
D 0 0.000000 0.0000 0.0000
S 11 19.000000 662.4800 512.4800
H 0 0.000000 0.0000 0.0000
T 4916 45145.500000 191209.7850 179582.2800
4192 8108.250000 153276.0100 155.3200
Other 0 0.000000 0.0000 0.0000
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Total 11884 55899.750000 466446.8050 224693.3600