CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 123 103.250000 3820.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 271 1052.750000 38951.7500 37.0000
Subtotal (Total Children Is Unduplicated) 271 1156.000000 42772.0000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 26.1000 13.0500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 18.2200 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.6800 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 43.4600 21.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 24.4700 24.4700
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 12.000000 900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 14.500000 804.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 185.000000 13875.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 68.000000 5100.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 44.500000 3337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 160 279.500000 15512.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 53.500000 4012.5000 75.0000
Subtotal (Total Children Is Unduplicated) 196 668.500000 43860.4300 65.6102
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Total 1824.500000 86632.4300 47.4828
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Number of Children (Unduplicated) With at Least One Service 271
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Center 10
Flag Claims Units Chgs Paid
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R 10 10.250000 379.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 917 1027.250000 49132.7500 0.0000
P 12 13.500000 439.1800 439.1800
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
705 773.500000 36681.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1644 1824.500000 86632.4300 439.1800