CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 51.3500 51.3500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 24.7800 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 75.9300 25.3100
EXIT-EXIT-EXIT ASSESSMENT 1 1.500000 75.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 12.000000 666.0000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 11.500000 638.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 26 41.000000 2140.3700 52.2041
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 417.1000 104.2750
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 13 11.500000 575.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.500000 12.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 241 286.750000 14337.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 8 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 31 158.750000 7937.5000 50.0000
INTR-T1013-INTERPRETER 1 4.250000 297.5000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 538 3319.000000 33190.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 26.000000 1857.4400 71.4400
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 285.7600 71.4400
TRAV-TRAVS-Travel by mile 471 49772.00000 22154.3000 0.4451
Subtotal (Total Children Is Unduplicated) 541 53590.75000 81182.6000 1.5149
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Total 53631.750000 83322.9700 1.5536
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Number of Children (Unduplicated) With at Least One Service 541
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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 4558 32320.250000 55133.5500 55133.5500
T 1674 11665.750000 20021.8500 20021.8500
643 9645.750000 8167.5700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6875 53631.750000 83322.9700 75155.4000