CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 17.9200 17.9200
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 12.6100 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 8.2600 8.2600
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 34.9700 34.9700
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.6800 20.6800
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.000000 345.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 5 9.500000 475.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 77 135.000000 10016.7900 74.1984
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 131 218.000000 16296.0300 74.7524
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 26.000000 1443.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 110.000000 8250.0000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 27 134.000000 6700.0000 50.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 2.000000 76.5700 38.2850
Subtotal (Total Children Is Unduplicated) 312 663.500000 45168.3800 68.0759
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 150 257.500000 12875.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 30 22.000000 550.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 21 24.000000 1200.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 18 22.000000 1100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 14.000000 700.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 32 35.000000 1750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1002 7121.000000 356050.0000 50.0000
INTR-T1013-INTERPRETER 4 69.000000 3128.0000 45.3333
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 72 511.000000 5110.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 105 733.500000 51087.1400 69.6485
PHY-97110-PT SESSION BY LICENSED PT 151 1166.000000 80290.0500 68.8594
SENS-V5050-IN EAR MONAURAL HEARING AID 3 5.000000 1140.0000 228.0000
SENS-V5264-EARMOLD 3 5.000000 90.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 369 3271.000000 225178.5200 68.8409
TRAV-TRAVS-Travel by mile 1357 136120.0000 60213.9200 0.4424
Subtotal (Total Children Is Unduplicated) 1416 149377.0000 800487.6300 5.3588
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Total 150040.500000 845656.0100 5.6362
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Number of Children (Unduplicated) With at Least One Service 1526
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Center 09
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 6159 141908.000000 423805.4500 423805.4500
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
2279 7851.500000 401282.5600 0.0000
Other 177 281.000000 20568.0000 0.0000
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Total 8615 150040.500000 845656.0100 423805.4500