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
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
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
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) 87 111.000000 5323.7100 47.9614
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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 314 1895.000000 128632.6000 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 49 19069.00000 13348.3000 0.7000
Subtotal (Total Children Is Unduplicated) 1119 37773.50000 719816.9900 19.0561
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Total 37884.500000 725140.7000 19.1408
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Number of Children (Unduplicated) With at Least One Service 1126
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Center 57
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 1 1.500000 101.8200 101.8200
D 0 0.000000 0.0000 0.0000
S 75 467.000000 5064.1400 5064.1400
H 0 0.000000 0.0000 0.0000
T 3265 28666.500000 261836.2100 261836.2100
2436 8630.000000 455382.3100 343310.3600
Other 41 119.500000 2756.2200 2756.2200
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Total 5818 37884.500000 725140.7000 613068.7500