CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/15/2012 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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.3400 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 65.1900 21.7300
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 25.2600 25.2600
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 27.2800 27.2800
EXIT-EXIT-TRANSITION ASSESSMENT 1 2.250000 112.5000 50.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 11.500000 862.5000 75.0000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 3 3.000000 145.5000 48.5000
Subtotal (Total Children Is Unduplicated) 16 26.750000 1508.5700 56.3951
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.000000 671.1800 223.7267
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 31 31.250000 1562.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 4 3.000000 75.0000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 119 259.250000 12962.5000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 21 13.000000 325.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 12 17.000000 850.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 17 45.000000 3299.4000 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 55 307.832000 15391.6000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 6.053624 410.9200 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 2 41.000000 2227.1200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 70.586600 4791.4190 67.8800
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 378 96860.00000 48430.0000 0.5000
Subtotal (Total Children Is Unduplicated) 395 97658.97222 91071.6390 0.9325
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Total 97685.722224 92580.2090 0.9477
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Number of Children (Unduplicated) With at Least One Service 397
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Center 53
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 0 0.000000 0.0000 0.0000
H 735 36457.053624 34874.5300 34874.5300
T 612 29604.250000 25821.8400 25821.8400
849 31624.418600 31883.8390 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2196 97685.722224 92580.2090 60696.3700