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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 974 952.000000 35205.5000 36.9806
TCM-T1017TL-TARGETED CASE MANAGEMENT 986 2880.750000 106587.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1581 3832.750000 141793.2500 36.9952
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 34 36.000000 516.9600 14.3600
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 18.4600 18.4600
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 35 37.000000 370.7400 10.0200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 35 37.000000 311.1700 8.4100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 35 37.000000 777.0000 21.0000
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.000000 62.6300 62.6300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 23 25.000000 550.5000 22.0200
EXIT-EXIT-EXIT ASSESSMENT 6 14.500000 725.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 63.500000 4762.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 17.000000 1275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 55.500000 3080.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 30.500000 2287.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.000000 679.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.000000 679.0000 48.5000
Subtotal (Total Children Is Unduplicated) 130 428.000000 19307.7100 45.1115
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 11.000000 7027.8800 638.8982
AUD-HA_FUP-AUDIOLOGY SERVICES 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 176 173.500000 8675.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 18 11.750000 587.5000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 4 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 32 27.000000 1350.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 1.250000 31.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 40 36.250000 1812.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 50 46.000000 2300.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 23 15.250000 381.2500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 316 3380.750000 169037.5000 50.0000
INTR-INTR-INTERPRETER 8 46.500000 2325.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 147 774.750000 51927.6500 67.0250
OCCT-97530HM-OT SESSION BY OT ASST 14 59.250000 3104.4000 52.3949
PHY-97110-PT SESSION BY LICENSED PT 152 774.750000 51289.6200 66.2015
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 268 1625.250000 108920.6500 67.0178
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 14 56.000000 3041.9200 54.3200
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 1088 14105.00000 141050.0000 10.0000
Subtotal (Total Children Is Unduplicated) 1257 21156.75000 553185.6200 26.1470
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Total 25417.500000 714286.5800 28.1022
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Number of Children (Unduplicated) With at Least One Service 2085
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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 7158 21359.750000 557199.5800 557199.5800
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
5509 4057.750000 157087.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 12667 25417.500000 714286.5800 557199.5800