CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 10.4200 10.4200
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 17.5000 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) 2 2.000000 45.8000 22.9000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 16.000000 888.0000 55.5000
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 4 7.500000 416.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 16.000000 1200.0000 75.0000
Subtotal (Total Children Is Unduplicated) 29 56.000000 3147.1100 56.1984
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 176 180.250000 9012.5000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 36 155.000000 7750.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 432 2154.000000 21540.0000 10.0000
TRAV-TRAVS-Travel by mile 352 29675.00000 13199.8300 0.4448
Subtotal (Total Children Is Unduplicated) 432 32168.25000 51677.3300 1.6065
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Total 32224.250000 54824.4400 1.7013
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Number of Children (Unduplicated) With at Least One Service 434
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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 1854 13454.500000 22875.4300 22875.4300
2535 18769.750000 31949.0100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4389 32224.250000 54824.4400 22875.4300