CMS/EIP Fiscal Report Center: 54
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 582 431.500000 15919.2500 36.8928
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 925 2878.750000 222.0000 0.0771
TCM-T1017TL-TARGETED CASE MANAGEMENT 1237 3537.750000 128723.0000 36.3856
Subtotal (Total Children Is Unduplicated) 1339 6848.000000 144864.2500 21.1542
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 13 15.000000 727.5000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 10.4200 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 70.0000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 24.1800 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.000000 174.7200 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 68.7000 22.9000
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 39 69.000000 3400.0000 49.2754
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 14.000000 1050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 8.500000 471.7500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 137 223.500000 16762.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 59.000000 4425.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 36.500000 2737.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 237 370.000000 20461.0000 55.3000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 110 167.500000 12525.0000 74.7761
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 102.1000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 372 1012.000000 64575.5700 63.8099
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 5.000000 670.0700 134.0140
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 103 46.000000 2287.5000 49.7283
CONIF-CONIF-CONSULT, FACE TO FACE 481 780.000000 38912.5000 49.8878
CONIP-CONIP-CONSULT, PHONE 6 26.750000 668.7500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 16 88.500000 4425.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 724 4520.750000 225876.0000 49.9643
INTR-T1013-INTERPRETER 39 208.000000 5225.0000 25.1202
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 981 7660.000000 76570.0000 9.9961
OCCT-97530-OT SESSION BY LICENSED OT 5 18.000000 1285.9200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 37 209.000000 14930.9599 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 62 394.000000 28147.3600 71.4400
TRAV-TRAVS-Travel by mile 634 61949.27000 27556.9800 0.4448
Subtotal (Total Children Is Unduplicated) 1003 75906.27000 426581.0399 5.6198
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Total 83766.270000 636020.8599 7.5928
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Number of Children (Unduplicated) With at Least One Service 1383
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Center 54
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 4796 4202.250000 184439.2500 0.0000
P 1 2.000000 74.0000 0.0000
D 3 5.500000 203.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 7157 27644.460000 95372.9088 95378.4700
T 6559 26245.700520 84360.0399 84273.0350
10710 25665.609480 271543.4112 0.0000
Other 1 0.750000 27.7500 0.0000
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Total 29227 83766.270000 636020.8599 179651.5050