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
Payclass Filters:GR
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 101 395.750000 14642.7500 37.0000
Subtotal (Total Children Is Unduplicated) 168 499.000000 18463.0000 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 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 11.500000 862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 17.500000 971.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 16 55.500000 3199.1800 57.6429
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Total 554.500000 21662.1800 39.0661
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Number of Children (Unduplicated) With at Least One Service 171
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Center 10
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 9 9.000000 130.9300 130.9300
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
570 545.500000 21531.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 579 554.500000 21662.1800 130.9300