CMS/EIP Fiscal Report Center: 10
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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 776 684.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2552 6383.500000 236134.0000 36.9913
Subtotal (Total Children Is Unduplicated) 2552 7068.000000 236134.0000 33.4089
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 10 10.000000 149.3000 14.9300
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 10 10.000000 104.2000 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 10 10.000000 87.5000 8.7500
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 10 10.000000 218.4000 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 91.6000 22.9000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 40.500000 3037.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 10.000000 750.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 35.500000 1970.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 391 774.500000 58087.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 155 263.500000 19762.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 103 171.500000 12862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 321 622.500000 34548.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 164 238.000000 17850.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 13.000000 612.6000 47.1231
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 510.5000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 597 2243.000000 151975.4500 67.7554
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 11.000000 1856.1100 168.7373
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 191 191.000000 9550.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 3.250000 81.2500 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 329 397.000000 19850.0000 50.0000
CONIP-CONIP-CONSULT, PHONE 30 26.500000 662.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1171 11245.50000 562250.0000 49.9978
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1356 15404.50000 154041.1600 9.9998
OCCT-97530-OT SESSION BY LICENSED OT 135 702.000000 49472.2000 70.4732
OCCT-97530HM-OT SESSION BY OT ASST 8 18.500000 1058.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 172 808.000000 56117.8400 69.4528
PHY-97110HM-PT SESSION BY PT ASST 1 2.500000 142.9000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 210 1194.500000 85288.2000 71.4008
SPL-92508-GROUP SPL SESSION PER CHILD 4 11.750000 163.0900 13.8800
Subtotal (Total Children Is Unduplicated) 1435 30016.00000 940533.4500 31.3344
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Total 39327.000000 1328642.9000 33.7845
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Number of Children (Unduplicated) With at Least One Service 2831
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Center 10
Flag Claims Units Chgs Paid
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R 270 175.250000 6484.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 6579 5135.000000 228799.2500 0.0000
P 7272 21560.750000 494796.3300 494777.8300
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
7505 12456.000000 598563.0700 10.0000
Other 0 0.000000 0.0000 0.0000
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Total 21626 39327.000000 1328642.9000 494787.8300