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: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 909 2835.750000 104922.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1417 3660.500000 135420.0000 36.9949
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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 4.000000 66.1300 16.5325
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 48 50.000000 455.5000 9.1100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 48 51.000000 476.3400 9.3400
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 7.9300 7.9300
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 48 50.000000 1082.3400 21.6468
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 5 9.000000 675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 29.500000 2212.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 14.500000 1087.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.500000 937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 56.500000 3135.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 15.500000 1162.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 12 12.000000 534.0000 44.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.000000 664.0000 47.4286
Subtotal (Total Children Is Unduplicated) 111 434.500000 15953.5200 36.7170
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 48.000000 1930.2900 40.2144
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 260 2706.500000 135325.0000 50.0000
INTR-INTR-INTERPRETER 5 63.250000 3162.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 111 547.250000 36908.1000 67.4429
OCCT-97530HM-OT SESSION BY OT ASST 19 87.000000 4581.5200 52.6611
PHY-97110-PT SESSION BY LICENSED PT 129 635.750000 42104.6400 66.2283
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 197 1079.750000 72938.4300 67.5512
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 15 46.000000 2498.7200 54.3200
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 954 239725.0000 119862.5000 0.5000
Subtotal (Total Children Is Unduplicated) 1076 245284.7500 437198.1700 1.7824
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Total 249379.750000 588571.6900 2.3601
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Number of Children (Unduplicated) With at Least One Service 1881
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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 6241 245566.750000 443059.4400 443059.4400
D 2 1.000000 37.0000 37.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5085 3812.000000 145475.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11328 249379.750000 588571.6900 443096.4400