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
Payclass Filters:GR
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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 21 21.000000 1018.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 12 12.000000 582.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 43 43.000000 2085.5000 48.5000
Subtotal (Total Children Is Unduplicated) 58 80.000000 3753.7100 46.9214
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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 25 25.750000 1287.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 17 17.000000 850.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 153 156.250000 7812.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 247 2117.500000 105875.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 18 69.000000 4683.7200 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 0.750000 40.7400 54.3200
PHY-97110-PT SESSION BY LICENSED PT 33 160.500000 10894.7400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 7.500000 407.4000 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 121 681.500000 46260.2200 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 18 59.500000 3232.0400 54.3200
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 719 6654.000000 66540.0000 10.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 49 19069.00000 13348.3000 0.7000
Subtotal (Total Children Is Unduplicated) 887 29020.00000 261319.6600 9.0048
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Total 29100.000000 265073.3700 9.1091
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Number of Children (Unduplicated) With at Least One Service 916
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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 0 0.000000 0.0000 0.0000
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 3258 28633.000000 260009.2300 260009.2300
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3333 29100.000000 265073.3700 265073.3700