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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 630 471.000000 17427.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 258 194.250000 7187.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1273 4148.000000 153476.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1301 4813.250000 178090.2500 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 12 16.500000 1237.5000 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 11 15.500000 860.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 187 218.500000 16387.5000 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 10 15.500000 1162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 246 322.000000 17871.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 124 170.500000 12787.5000 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) 461 994.000000 62167.4600 62.5427
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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 725 6783.500000 339175.0000 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 722 6743.000000 67430.0000 10.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 52 19272.00000 13490.4000 0.7000
Subtotal (Total Children Is Unduplicated) 1125 37994.50000 720877.8900 18.9732
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Total 43801.750000 961135.6000 21.9429
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Number of Children (Unduplicated) With at Least One Service 1475
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Center 57
Flag Claims Units Chgs Paid
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R 33 22.500000 832.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1710 1355.250000 55035.5000 0.0000
P 1309 1298.750000 54936.3200 54890.0700
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 3271 28873.500000 262018.3100 262018.3100
6519 11635.000000 579175.1100 343510.3600
Other 41 119.500000 2756.2200 2756.2200
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Total 12994 43801.750000 961135.6000 668239.1000