CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 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) 3 3.000000 26.2500 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 16.1200 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 65.5200 21.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 22.9000 22.9000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 25.5300 25.5300
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 46.8000 46.8000
EXIT-EXIT-EXIT ASSESSMENT 2 2.500000 125.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 11.509333 863.2000 75.0000
Subtotal (Total Children Is Unduplicated) 17 33.509333 1731.3200 51.6668
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 1364.7700 341.1925
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 19.000000 950.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 200 241.000000 12050.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 39 182.250000 9112.5000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 200.0000 100.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 486 2422.000000 24220.0000 10.0000
TRAV-TRAVS-Travel by mile 406 31023.00000 13802.2400 0.4449
Subtotal (Total Children Is Unduplicated) 489 33896.25000 61774.5100 1.8225
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Total 33929.759333 63505.8300 1.8717
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Number of Children (Unduplicated) With at Least One Service 491
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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 1993 13181.750000 23633.4600 23633.4600
T 0 0.000000 0.0000 0.0000
3072 20739.009333 39782.3700 0.0000
Other 9 9.000000 90.0000 0.0000
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Total 5074 33929.759333 63505.8300 23633.4600