CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 1041 960.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2938 8658.250000 320317.0000 36.9956
Subtotal (Total Children Is Unduplicated) 2939 9618.750000 320317.0000 33.3013
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 6 6.000000 89.5800 14.9300
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 62.5200 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 52.5000 8.7500
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 131.0400 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 91.6000 22.9000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 23.500000 1762.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 17.000000 943.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 406 733.000000 54975.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 161 274.500000 20587.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 120 194.500000 14587.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 377 659.500000 36602.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 146 230.500000 17287.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 15 16.000000 765.7500 47.8594
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 26 27.000000 1378.3500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 641 2230.500000 151102.5900 67.7438
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 199 171.250000 8562.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 7 5.500000 137.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 315 337.000000 16850.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 26 26.000000 650.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 6.500000 325.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 24 20.000000 1000.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.250000 6.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1390 12953.75000 647687.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1534 17282.00000 172820.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 187 1129.500000 79459.1400 70.3490
OCCT-97530HM-OT SESSION BY OT ASST 8 30.500000 1401.4000 45.9475
PHY-97110-PT SESSION BY LICENSED PT 221 1371.500000 93907.8800 68.4709
PHY-97110HM-PT SESSION BY PT ASST 2 5.500000 314.3800 57.1600
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 283 1887.000000 132896.2600 70.4273
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.500000 85.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 2 5.000000 69.4000 13.8800
Subtotal (Total Children Is Unduplicated) 1685 35238.25000 1156371.5100 32.8158
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Total 47087.500000 1627791.1000 34.5695
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Number of Children (Unduplicated) With at Least One Service 3166
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Center 10
Flag Claims Units Chgs Paid
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R 77 47.250000 1748.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 9325 6685.500000 281593.2500 0.0000
P 8653 25331.500000 640520.0400 640520.0400
D 71 38.250000 1415.2500 0.0000
S 191 151.500000 5605.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9204 14833.250000 696899.5600 0.0000
Other 1 0.250000 9.2500 0.0000
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Total 27522 47087.500000 1627791.1000 640520.0400