CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 37.3600 9.3400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 86.9200 21.7300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 24.4700 24.4700
EXIT-EXIT-EXIT ASSESSMENT 9 17.250000 862.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 16.000000 1200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 35.000000 1942.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 2.000000 97.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 7.000000 339.5000 48.5000
Subtotal (Total Children Is Unduplicated) 58 108.750000 5982.2500 55.0092
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 5.000000 250.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PRO, BY PHONE 2 0.500000 12.5000 25.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 67 83.750000 4187.5000 50.0000
CONIP-CONIP-CONSULT, ITDS, PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 3.750000 187.5000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 6.000000 300.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 239 845.250000 42262.5000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 2 2.000000 100.0000 50.0000
INTR-INTR-INTERPRETER 4 47.000000 940.0000 20.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 104.500000 7079.9000 67.7502
OCCT-97530HM-OT SESSION BY OT ASST 3 5.000000 271.6000 54.3200
PHY-97110-PT SESSION BY LICENSED PT 49 176.000000 11946.8800 67.8800
PHY-97110HM-PT SESSION BY PT ASST 3 22.000000 1195.0400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 64 223.250000 15154.2100 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 54.3200 54.3200
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 383 49460.00000 24710.0000 0.4996
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 2 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 406 50992.50000 109014.4500 2.1379
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Total 51101.250000 114996.7000 2.2504
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Number of Children (Unduplicated) With at Least One Service 407
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Center 54
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 988 45973.163000 42112.4100 42112.4100
T 0 0.000000 0.0000 0.0000
1314 5128.087000 72884.2900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2302 51101.250000 114996.7000 42112.4100