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
Payclass Filters:GR
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 103 421.500000 15595.5000 37.0000
Subtotal (Total Children Is Unduplicated) 169 537.000000 19869.0000 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 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 26.500000 1987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 23.000000 1276.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.500000 412.5000 75.0000
Subtotal (Total Children Is Unduplicated) 27 93.000000 5343.7200 57.4594
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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 636.500000 25546.6600 40.1362
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Number of Children (Unduplicated) With at Least One Service 181
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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 23 25.500000 615.1600 615.1600
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
574 611.000000 24931.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 597 636.500000 25546.6600 615.1600