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
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) 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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 21 42.250000 1989.7500 47.0947
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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 65 63.250000 3162.5000 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 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 33 105.200000 5260.0000 50.0000
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 1.000000 50.0000 50.0000
INTR-INTR-INTERPRETER 4 47.000000 940.0000 20.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 16.335800 1108.8700 67.8797
OCCT-97530HM-OT SESSION BY OT ASST 2 3.500000 190.1200 54.3200
PHY-97110-PT SESSION BY LICENSED PT 18 38.665400 2624.5600 67.8788
PHY-97110HM-PT SESSION BY PT ASST 2 2.000000 108.6400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 83.750000 5684.9500 67.8800
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) 397 49841.45120 44852.1400 0.8999
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Total 49883.701200 46841.8900 0.9390
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Number of Children (Unduplicated) With at Least One Service 397
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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
109 3910.538200 4729.4800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1097 49883.701200 46841.8900 42112.4100