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
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 1030 806.250000 29794.2500 36.9541
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 550 1415.000000 111.0000 0.0784
TCM-T1017TL-TARGETED CASE MANAGEMENT 465 1683.250000 61735.0000 36.6761
Subtotal (Total Children Is Unduplicated) 1309 3904.500000 91640.2500 23.4704
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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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 18.000000 1350.0000 75.0000
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 76 234.000000 12987.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 58 119.500000 8962.5000 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 1 1.000000 50.0000 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 4 4.000000 204.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 164 495.250000 29167.8600 58.8952
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EI Services,Class #03
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 276 1631.500000 80528.1000 49.3583
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 58.750000 3799.1100 64.6657
PHY-97110-PT SESSION BY LICENSED PT 8 43.000000 2592.9900 60.3021
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 292.750000 20477.8200 69.9499
TRAV-TRAVS-Travel by mile 96 3411.000000 1518.9050 0.4453
Subtotal (Total Children Is Unduplicated) 1037 12517.75000 198911.9250 15.8904
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Total 16917.500000 319720.0350 18.8988
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Number of Children (Unduplicated) With at Least One Service 1639
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Center 07
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 3238 12588.500000 203809.7500 203809.7500
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
5396 4325.000000 115610.2850 543.0000
Other 0 0.000000 0.0000 0.0000
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Total 8636 16917.500000 319720.0350 204352.7500