CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2016 ending 06/30/2016 Date of Report:08/07/2016 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-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 14.9300 14.9300
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 10.4200 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 2.000000 17.5000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 2.000000 16.1200 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 3.000000 65.5200 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 22.9000 22.9000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
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 2 3.500000 194.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
Subtotal (Total Children Is Unduplicated) 10 25.000000 1204.1400 48.1656
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 28 158.000000 7900.0000 50.0000
TRAV-TRAVS-Travel by mile 1 54.000000 24.0300 0.4450
Subtotal (Total Children Is Unduplicated) 28 212.000000 7924.0300 37.3775
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Total 237.000000 9128.1700 38.5155
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Number of Children (Unduplicated) With at Least One Service 36
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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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
178 237.000000 9128.1700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 178 237.000000 9128.1700 0.0000