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:OTHER
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-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 2 3.000000 265.0000 88.3333
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 25.000000 1250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 67.8800 67.8800
PHY-97110-PT SESSION BY LICENSED PT 2 2.500000 169.7000 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 203.6400 67.8800
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 18 85.000000 850.0000 10.0000
Subtotal (Total Children Is Unduplicated) 24 118.500000 2641.2200 22.2888
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Total 121.500000 2906.2200 23.9195
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Number of Children (Unduplicated) With at Least One Service 26
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Center 57
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 2.000000 150.0000 0.0000
Other 41 119.500000 2756.2200 2756.2200
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Total 42 121.500000 2906.2200 2756.2200