CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 1241 956.750000 35362.7500 36.9613
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 734 1147.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 511 1766.500000 65147.7500 36.8796
Subtotal (Total Children Is Unduplicated) 1527 3871.000000 100510.5000 25.9650
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Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 17.5000 8.7500
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 43.6800 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 45.8000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 68 109.250000 5462.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 48.000000 3600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.500000 254.6500 72.7571
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 72 134.000000 7437.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 74 176.000000 13200.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 102.1000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 13 13.000000 663.6500 51.0500
Subtotal (Total Children Is Unduplicated) 196 510.750000 31956.6800 62.5681
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EI Services,Class #03
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 59 60.500000 3025.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 109 440.250000 22012.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 5 5.000000 125.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 294 2074.750000 103160.3000 49.7218
INTR-T1013-INTERPRETER 7 60.000000 3170.0000 52.8333
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1091 8240.000000 82498.9400 10.0120
OCCT-97530-OT SESSION BY LICENSED OT 9 70.000000 4929.1200 70.4160
PHY-97110-PT SESSION BY LICENSED PT 9 60.000000 4272.1200 71.2020
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 290.750000 18849.2400 64.8297
TRAV-TRAVS-Travel by mile 25 823.000000 366.2900 0.4451
Subtotal (Total Children Is Unduplicated) 1101 12126.25000 242508.5100 19.9986
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Total 16508.000000 374975.6900 22.7148
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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 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 4488 12240.750000 249234.9400 249164.9400
D 87 67.250000 2753.2500 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
6639 4200.000000 122987.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11214 16508.000000 374975.6900 249164.9400