CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 17.5000 8.7500
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 8.0600 8.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 43.6800 21.8400
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 46.8000 46.8000
EXIT-EXIT-EXIT ASSESSMENT 8 15.000000 750.0000 50.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 20.500000 1137.7500 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 10.000000 750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 127.500000 7076.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 32.500000 2437.5000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 132 225.000000 13208.1900 58.7031
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 17 56.000000 8864.7600 158.2993
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 31 16.000000 800.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 402 365.250000 18262.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 14 5.750000 118.0000 20.5217
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 58.000000 2900.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 433 2359.500000 117935.0000 49.9830
INTR-T1013-INTERPRETER 33 115.500000 2887.5000 25.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 718 4043.000000 40430.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 56.000000 4000.6400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 23 106.000000 7572.6400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 135.750000 9697.9800 71.4400
TRAV-TRAVS-Travel by mile 636 51180.00000 22782.2800 0.4451
Subtotal (Total Children Is Unduplicated) 739 58496.75000 236251.3000 4.0387
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Total 58721.750000 249459.4900 4.2482
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Number of Children (Unduplicated) With at Least One Service 739
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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 1 1.000000 50.0000 50.0000
D 0 0.000000 0.0000 0.0000
S 3 3.000000 38.6500 0.0000
H 3456 22299.480000 52549.5100 52549.5100
T 4177 25306.750000 56429.4400 56429.4400
3705 11111.520000 140391.8900 88404.0700
Other 0 0.000000 0.0000 0.0000
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Total 11342 58721.750000 249459.4900 197433.0200