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:TPIN
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) 1 1.000000 8.7500 8.7500
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 21.8400 21.8400
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 6 9.000000 499.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.000000 750.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 13 24.500000 1454.0600 59.3494
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 29.000000 1450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 7.000000 500.0800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 5 15.359480 1097.2812 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 17.000000 1214.4800 71.4400
TRAV-TRAVS-Travel by mile 1 50.000000 22.2500 0.4450
Subtotal (Total Children Is Unduplicated) 19 118.359480 4284.0912 36.1956
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Total 142.859480 5738.1512 40.1664
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Number of Children (Unduplicated) With at Least One Service 29
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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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
88 142.859480 5738.1512 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 88 142.859480 5738.1512 0.0000