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
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 578 426.000000 15715.7500 36.8914
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 924 2876.250000 222.0000 0.0772
TCM-T1017TL-TARGETED CASE MANAGEMENT 289 705.500000 25733.5000 36.4755
Subtotal (Total Children Is Unduplicated) 1129 4007.750000 41671.2500 10.3977
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 13 15.000000 727.5000 48.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 7.000000 61.2500 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 24.1800 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 152.8800 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 68.7000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 38 67.000000 3300.0000 49.2537
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
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 7 12.000000 900.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.500000 412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 59.000000 3237.5000 54.8729
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 27.500000 2062.5000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 111 228.000000 12534.0600 54.9739
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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 481 778.500000 38837.5000 49.8876
CONIP-CONIP-CONSULT, PHONE 6 26.750000 668.7500 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 98 559.000000 27937.5000 49.9776
INTR-T1013-INTERPRETER 39 208.000000 5225.0000 25.1202
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 981 7655.000000 76520.0000 9.9961
OCCT-97530-OT SESSION BY LICENSED OT 4 11.000000 785.8400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 26 124.640520 8904.3187 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 346.000000 24718.2400 71.4400
TRAV-TRAVS-Travel by mile 634 61899.27000 27534.7300 0.4448
Subtotal (Total Children Is Unduplicated) 989 71747.66052 218514.4487 3.0456
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Total 75983.410520 272719.7587 3.5892
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Number of Children (Unduplicated) With at Least One Service 1253
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 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 6557 26243.700520 84273.0399 84273.0350
7146 22089.750000 92870.3100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 20863 75983.410520 272719.7587 179651.5050