CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2016 ending 06/30/2016 Date of Report:08/06/2016 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-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 14.9300 14.9300
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 20.8400 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 4.000000 35.0000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 4.000000 32.2400 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 4.000000 87.3600 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 68.7000 22.9000
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 48.000000 2664.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.000000 1125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 34 61.500000 3413.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 76.000000 5700.0000 75.0000
Subtotal (Total Children Is Unduplicated) 101 230.000000 13973.8200 60.7557
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 33 20.000000 1000.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 258 405.250000 20260.0000 49.9938
CONIP-CONIP-CONSULT, ITDS PHONE 23 7.750000 193.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.250000 12.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 401 2841.500000 142050.0000 49.9912
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 555 4031.000000 40310.0000 10.0000
TRAV-TRAVS-Travel by mile 468 51230.00000 22804.0200 0.4451
Subtotal (Total Children Is Unduplicated) 556 58536.75000 226655.2700 3.8720
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Total 58766.750000 240629.0900 4.0946
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Number of Children (Unduplicated) With at Least One Service 560
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Center 53
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 8241 55897.500000 97408.6700 97402.0000
T 0 0.000000 0.0000 0.0000
2742 2869.250000 143220.4200 200.0000
Other 0 0.000000 0.0000 0.0000
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Total 10983 58766.750000 240629.0900 97602.0000