CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 10.4200 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 70.0000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 24.1800 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.000000 174.7200 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 68.7000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 14 18.750000 937.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 12.500000 937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 10.500000 787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 58 96.000000 5328.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 64.500000 4837.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 102.1000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 128 239.250000 14038.0200 58.6751
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 5.000000 670.0700 134.0140
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 415 393.250000 19662.5000 50.0000
CONIP-CONIP-CONSULT, PHONE 1 0.750000 18.7500 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 16 88.500000 4425.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 393 2807.750000 140338.5000 49.9825
INTR-T1013-INTERPRETER 38 207.000000 5175.0000 25.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 681 5040.000000 50400.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 18.000000 1285.9200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 37 209.000000 14930.9599 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 62 394.000000 28147.3600 71.4400
TRAV-TRAVS-Travel by mile 592 61381.47000 27304.2100 0.4448
Subtotal (Total Children Is Unduplicated) 691 70545.72000 292408.2699 4.1449
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Total 70784.970000 306446.2899 4.3293
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Number of Children (Unduplicated) With at Least One Service 692
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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 4169 25220.510000 61874.1388 61889.7000
T 3957 24011.100520 55701.7899 55701.7850
5896 21553.359480 188870.3612 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14022 70784.970000 306446.2899 117591.4850