CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 122 115.500000 4273.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 253 1026.000000 37962.0000 37.0000
Subtotal (Total Children Is Unduplicated) 253 1141.500000 42235.5000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.000000 57.4400 14.3600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.000000 40.0800 10.0200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 33.6400 8.4100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 84.0000 21.0000
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 66.0600 22.0200
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 109 170.000000 12750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 69.000000 5175.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 52.500000 3937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 128 207.500000 11516.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 43 53.000000 3975.0000 75.0000
Subtotal (Total Children Is Unduplicated) 189 600.500000 39593.9700 65.9350
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EI Services,Class #03
INTR-INTR-INTERPRETER 2 6.000000 300.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 33.9400 67.8800
Subtotal (Total Children Is Unduplicated) 3 6.500000 333.9400 51.3754
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Total 1748.500000 82163.4100 46.9908
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Number of Children (Unduplicated) With at Least One Service 254
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Center 10
Flag Claims Units Chgs Paid
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R 6 6.250000 231.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 705 717.250000 30134.0000 0.0000
P 133 188.000000 11583.9100 11583.9100
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
717 837.000000 40214.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1561 1748.500000 82163.4100 11583.9100