CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 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 718 1788.250000 66165.2500 37.0000
Subtotal (Total Children Is Unduplicated) 718 1788.250000 66165.2500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 21 21.000000 199.5000 9.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 71.9300 8.9913
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 21 21.000000 449.7600 21.4171
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 56.9400 56.9400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 45.000000 3375.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 52.000000 3900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 64.500000 4837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 114 194.500000 10794.7500 55.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 97.0000 48.5000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 142 430.000000 25122.1300 58.4236
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 29 97.250000 4862.5000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 4 3.250000 220.6100 67.8800
Subtotal (Total Children Is Unduplicated) 33 100.500000 5083.1100 50.5782
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Total 2318.750000 96370.4900 41.5614
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Number of Children (Unduplicated) With at Least One Service 729
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Center 03
Flag Claims Units Chgs Paid
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R 40 31.000000 1324.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1803 1245.000000 52756.3600 9.2500
P 1568 991.750000 41511.2500 41511.2550
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
0 0.000000 0.0000 0.0000
Other 51 51.000000 778.1300 0.0000
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Total 3462 2318.750000 96370.4900 41520.5050