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:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1521 4417.500000 163447.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1521 4417.500000 163447.5000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 13.0500 13.0500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 9.1100 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.3400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.7300 21.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 24.4700 24.4700
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 19.500000 1462.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 7.500000 562.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 35.000000 1942.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 115 204.000000 15300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 55.500000 4162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 54 95.000000 7125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 141 265.500000 14735.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 106 130.000000 9750.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 239 837.000000 56432.4500 67.4223
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 476 4147.500000 207375.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 98 466.500000 31547.2300 67.6254
OCCT-97530HM-OT SESSION BY OT ASST 6 15.500000 841.9600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 177 701.000000 47583.8800 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 126 589.750000 40032.2300 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 5.500000 298.7600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 2 4.500000 59.4000 13.2000
Subtotal (Total Children Is Unduplicated) 697 5930.250000 327738.4600 55.2655
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Total 11184.750000 547618.4100 48.9612
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Number of Children (Unduplicated) With at Least One Service 1559
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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 10 17.500000 1188.3800 1120.5000
D 0 0.000000 0.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2104 5944.750000 328321.0300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9794 11184.750000 547618.4100 1120.5000