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
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) 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 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 27.500000 1526.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
Subtotal (Total Children Is Unduplicated) 33 59.500000 3197.7900 53.7444
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 17 48.640000 8100.3900 166.5376
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 77 358.250000 17912.5000 50.0000
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 6 16.000000 1143.0400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 14 49.050000 3500.2500 71.3609
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 117.750000 8412.0600 71.4400
TRAV-TRAVS-Travel by mile 624 50398.00000 22434.1700 0.4451
Subtotal (Total Children Is Unduplicated) 739 55591.19000 126900.4100 2.2827
-----------------------------------------------------------------------------------------------------------------------
Total 55650.690000 130098.2000 2.3378
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 739
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 3 3.000000 38.6500 0.0000
H 3456 22299.480000 52549.5100 52549.5100
T 4177 25306.750000 56429.4400 56429.4400
1424 8041.460000 21080.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9060 55650.690000 130098.2000 108978.9500