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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 1.250000 46.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 724 720.250000 26630.7500 36.9743
TCM-T1017TL-TARGETED CASE MANAGEMENT 2286 6857.500000 253727.5000 37.0000
Subtotal (Total Children Is Unduplicated) 2286 7579.000000 280404.5000 36.9976
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 46 47.000000 613.3500 13.0500
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 5.000000 67.1200 13.4240
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 48 50.000000 455.5000 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 47 50.000000 467.0000 9.3400
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 7.9300 7.9300
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 48 51.000000 1086.5000 21.3039
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 40 42.000000 1027.7400 24.4700
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 3 6.000000 690.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 1 3.500000 175.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 40.000000 3000.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 17.000000 1275.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 10.500000 787.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 51.500000 2858.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 193 342.000000 25650.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 66 107.500000 8062.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 86 151.000000 11325.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 233 445.500000 24725.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 160 208.500000 15637.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 20 21.000000 970.0000 46.1905
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 18 19.000000 873.0000 45.9474
Subtotal (Total Children Is Unduplicated) 435 1686.000000 100871.5800 59.8289
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 80.000000 5386.7500 67.3344
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 122 128.000000 6400.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 5 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 31 18.000000 900.0000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 8 3.500000 87.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 22 18.000000 900.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 10 3.750000 93.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 27 23.750000 1187.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 6 2.750000 68.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 76 56.500000 2825.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 27 14.250000 356.2500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 52.000000 1300.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 9.000000 450.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 709 6854.000000 342700.0000 50.0000
INTR-INTR-INTERPRETER 5 63.250000 3162.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 233 1182.750000 79593.3100 67.2951
OCCT-97530HM-OT SESSION BY OT ASST 24 122.500000 6411.8000 52.3412
PHY-97110-PT SESSION BY LICENSED PT 354 1620.000000 108146.4700 66.7571
PHY-97110HM-PT SESSION BY PT ASST 3 2.250000 122.2200 54.3200
SENS-HA_EIP-ONE UNIT UP TO $500 PER AID 3 6.000000 3000.0000 500.0000
SENS-V5264-EARMOLD 3 6.000000 108.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 355 1851.500000 125068.9000 67.5500
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 19 54.500000 2960.4400 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.500000 59.4000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 954 239725.0000 119862.5000 0.5000
Subtotal (Total Children Is Unduplicated) 1185 251904.2500 811238.5400 3.2204
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Total 261169.250000 1192514.6200 4.5661
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Number of Children (Unduplicated) With at Least One Service 2339
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Center 10
Flag Claims Units Chgs Paid
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R 220 120.750000 4467.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 7459 5101.500000 213632.0000 0.0000
P 6242 245575.250000 444116.8900 444049.0100
D 2 1.000000 37.0000 37.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7256 10370.500000 530251.7300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 21180 261169.250000 1192514.6200 444086.0100