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
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 413 231.750000 8574.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 395 2317.750000 74.0000 0.0319
TCM-T1017TL-TARGETED CASE MANAGEMENT 265 710.500000 26159.0000 36.8177
Subtotal (Total Children Is Unduplicated) 682 3260.000000 34807.7500 10.6772
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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
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 39.500000 2645.2800 66.9691
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 530.0000 66.2500
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 23.000000 1129.7900 49.1213
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 5 6.000000 306.3000 51.0500
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 48 106.500000 6449.9800 60.5632
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 107 130.000000 6500.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 176 441.000000 22031.2500 49.9575
CONIP-CONIP-CONSULT, PHONE 9 9.000000 222.0000 24.6667
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 64 333.250000 16572.5000 49.7299
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 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 16 125.500000 8648.6700 68.9137
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 116 652.000000 44167.4500 67.7415
TRAV-TRAVS-Travel by mile 584 41723.00000 18561.3150 0.4449
Subtotal (Total Children Is Unduplicated) 673 47778.25000 173417.9050 3.6296
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Total 51144.750000 214675.6350 4.1974
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Number of Children (Unduplicated) With at Least One Service 901
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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 10 17.000000 512.4800 512.4800
H 0 0.000000 0.0000 0.0000
T 4643 44850.500000 171525.0450 167392.4700
3005 6276.500000 42584.5300 155.3200
Other 0 0.000000 0.0000 0.0000
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Total 7659 51144.750000 214675.6350 168113.8500