CMS/EIP Fiscal Report Center: 07
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 1030 806.250000 29794.2500 36.9541
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 550 1415.000000 111.0000 0.0784
TCM-T1017TL-TARGETED CASE MANAGEMENT 1474 4748.000000 174779.2500 36.8111
Subtotal (Total Children Is Unduplicated) 1558 6969.250000 204684.5000 29.3697
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 14.9300 14.9300
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 26.2500 8.7500
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 43.6800 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 22.9000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 57 101.750000 5087.5000 50.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 16.000000 1200.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 19.500000 1237.5000 63.4615
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 206 475.000000 26362.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 182 403.000000 30225.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 25.0600 25.0600
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 15.6900 7.8450
SCREEN-T1023-SCREENING 15 15.000000 750.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 2.000000 51.0500 25.5250
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 6.000000 306.3000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 351 1055.250000 65806.4600 62.3610
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EI Services,Class #03
AUD-92633-AUD REHAB POSTLING HEARING LOSS 1 2.000000 143.2200 71.6100
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 22 23.500000 1175.0000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 88 399.000000 19950.0000 50.0000
CONIP-CONIP-CONSULT, PHONE 5 6.500000 162.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 303 1710.000000 84453.1000 49.3878
INTR-T1013-INTERPRETER 7 46.750000 2657.5000 56.8449
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1029 6605.000000 66050.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 59.750000 3800.1100 63.6002
PHY-97110-PT SESSION BY LICENSED PT 8 43.000000 2592.9900 60.3021
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 298.750000 20906.4600 69.9798
TRAV-TRAVS-Travel by mile 96 3411.000000 1518.9050 0.4453
Subtotal (Total Children Is Unduplicated) 1044 12605.25000 203409.7850 16.1369
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Total 20629.750000 473900.7450 22.9717
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Number of Children (Unduplicated) With at Least One Service 1748
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Center 07
Flag Claims Units Chgs Paid
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R 28 18.000000 666.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 71 47.250000 1828.0000 0.0000
P 7851 16133.750000 350042.5000 349911.5000
D 0 0.000000 0.0000 0.0000
S 2 4.000000 300.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5456 4426.750000 121064.2450 543.0000
Other 0 0.000000 0.0000 0.0000
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Total 13408 20629.750000 473900.7450 350454.5000