CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 607 452.000000 16724.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 236 178.250000 6595.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1217 3939.000000 145743.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1245 4569.250000 169062.2500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 13.0500 13.0500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 9.1100 9.1100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.0000 21.0000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 24.5500 24.5500
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 112 112.000000 5600.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 15.000000 1125.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 162 187.000000 14025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 208 271.500000 15068.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 104 142.000000 10650.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 24 24.000000 1164.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 22 22.000000 1067.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 60 60.000000 2910.0000 48.5000
Subtotal (Total Children Is Unduplicated) 418 878.500000 54518.9600 62.0591
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.750000 87.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 26 26.750000 1337.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 17 17.000000 850.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 154 157.250000 7862.5000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 20 1069.000000 26725.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 724 6779.500000 338975.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 148 1016.000000 68966.0800 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 4 12.250000 665.4200 54.3200
PHY-97110-PT SESSION BY LICENSED PT 153 847.750000 57545.2700 67.8800
PHY-97110HM-PT SESSION BY PT ASST 6 39.250000 2132.0600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 316 1905.000000 129311.4000 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 26 95.500000 5187.5600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 9 8.500000 112.2000 13.2000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 721 6739.000000 67390.0000 10.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 50 19084.00000 13358.8000 0.7000
Subtotal (Total Children Is Unduplicated) 1122 37798.50000 720506.2900 19.0618
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Total 43246.250000 944087.5000 21.8305
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Number of Children (Unduplicated) With at Least One Service 1419
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Center 57
Flag Claims Units Chgs Paid
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R 31 21.000000 777.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1655 1295.750000 52108.2500 0.0000
P 1232 1199.250000 50351.3200 50305.0700
D 36 30.250000 1317.5000 0.0000
S 75 467.000000 5064.1400 5064.1400
H 0 0.000000 0.0000 0.0000
T 3266 28681.500000 261846.7100 261846.7100
6329 11432.000000 569866.3600 343310.3600
Other 41 119.500000 2756.2200 2756.2200
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Total 12665 43246.250000 944087.5000 663282.5000