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:Program Patients
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 847 823.500000 30451.0000 36.9775
TCM-T1017TL-TARGETED CASE MANAGEMENT 2557 7910.250000 292679.2500 37.0000
Subtotal (Total Children Is Unduplicated) 2557 8735.000000 323176.5000 36.9979
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 48 49.000000 639.4500 13.0500
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 4 5.000000 67.1200 13.4240
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 50 52.000000 473.7200 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 49 52.000000 485.6800 9.3400
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 7.9300 7.9300
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 50 53.000000 1129.9600 21.3200
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 41 43.000000 1052.2100 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 31 52.000000 3900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 19.500000 1462.5000 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 37 66.000000 3663.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 306 527.000000 39525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 111 175.500000 13162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 115 195.500000 14662.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 393 725.000000 40237.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 202 262.000000 19650.0000 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) 631 2354.500000 144732.0100 61.4704
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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 262993.750000 1279147.0500 4.8638
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Number of Children (Unduplicated) With at Least One Service 2610
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Center 10
Flag Claims Units Chgs Paid
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R 230 131.000000 4847.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8376 6128.750000 262764.7500 0.0000
P 6254 245588.750000 444556.0700 444488.1900
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
7961 11144.000000 566932.9800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 22824 262993.750000 1279147.0500 444525.1900