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
Payclass Filters:GR
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 559 1870.000000 69190.0000 37.0000
Subtotal (Total Children Is Unduplicated) 954 2535.250000 93804.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
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
EXIT-EXIT-EXIT ASSESSMENT 112 112.000000 5600.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.500000 412.5000 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 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 91 109.000000 8175.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.500000 787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 115 152.000000 8436.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 76.500000 5737.5000 75.0000
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) 292 557.500000 33714.4600 60.4744
-----------------------------------------------------------------------------------------------------------------------
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 123 691.500000 46939.0200 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 720 6658.000000 66580.0000 10.0000
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 52 19272.00000 13490.4000 0.7000
Subtotal (Total Children Is Unduplicated) 893 29237.00000 262180.5600 8.9674
-----------------------------------------------------------------------------------------------------------------------
Total 32329.750000 389699.2700 12.0539
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1274
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 36 30.250000 1317.5000 0.0000
S 75 467.000000 5064.1400 5064.1400
H 0 0.000000 0.0000 0.0000
T 3264 28840.000000 260191.3300 260191.3300
4069 2992.500000 123126.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7444 32329.750000 389699.2700 265255.4700