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
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) 7 7.000000 61.2500 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 24.1800 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 152.8800 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
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 12.000000 666.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 11.500000 862.5000 75.0000
Subtotal (Total Children Is Unduplicated) 40 69.250000 3259.0100 47.0615
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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 60 378.000000 18900.0000 50.0000
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 4 11.000000 785.8400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 26 124.640520 8904.3187 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 346.000000 24718.2400 71.4400
TRAV-TRAVS-Travel by mile 592 61331.47000 27281.9600 0.4448
Subtotal (Total Children Is Unduplicated) 691 67926.61052 160991.6787 2.3701
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Total 67995.860520 164250.6887 2.4156
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Number of Children (Unduplicated) With at Least One Service 691
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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
3184 18764.250000 46674.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11310 67995.860520 164250.6887 117591.4850