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:TPIN
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 6 5.500000 203.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 2.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 50 106.750000 3959.0000 37.0867
Subtotal (Total Children Is Unduplicated) 53 114.750000 4162.5000 36.2745
-----------------------------------------------------------------------------------------------------------------------
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
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 34.000000 2550.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 10.000000 750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.500000 412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 34.000000 1887.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 23.500000 1725.0000 73.4043
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 53 117.000000 7791.5600 66.5945
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONIF-CONIF-CONSULT, FACE TO FACE 2 1.500000 75.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 70 257.000000 12875.0000 50.0973
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 7.000000 500.0800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 5 15.359480 1097.2812 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 17.000000 1214.4800 71.4400
TRAV-TRAVS-Travel by mile 1 50.000000 22.2500 0.4450
Subtotal (Total Children Is Unduplicated) 81 352.859480 15834.0912 44.8736
-----------------------------------------------------------------------------------------------------------------------
Total 584.609480 27788.1512 47.5328
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 148
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
551 584.609480 27788.1512 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 551 584.609480 27788.1512 0.0000