CMS/EIP Fiscal Report Center: 54
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
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 12.6100 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 16.5200 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 25.3100 25.3100
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 34.9700 34.9700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 18.5500 18.5500
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
EXIT-EXIT-EXIT ASSESSMENT 14 26.750000 1337.5000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 25.500000 1415.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
Subtotal (Total Children Is Unduplicated) 37 74.250000 3794.7700 51.1080
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 7.000000 2641.6300 377.3757
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 15 15.500000 775.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 460 616.500000 30825.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 15 6.500000 162.5000 25.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 4.000000 293.2800 73.3200
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 13 69.750000 3487.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 74 386.930000 19346.5000 50.0000
INTR-T1013-INTERPRETER 30 158.750000 4173.7500 26.2913
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 850 6567.000000 65650.0000 9.9970
OCCT-97530-OT SESSION BY LICENSED OT 10 39.760000 2840.3100 71.4364
PHY-97110-PT SESSION BY LICENSED PT 12 54.200000 3869.6600 71.3959
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 7.000000 500.0800 71.4400
TRAV-TRAVS-Travel by mile 802 88663.00000 39466.5700 0.4451
Subtotal (Total Children Is Unduplicated) 864 96598.89000 174117.7800 1.8025
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Total 96673.140000 177912.5500 1.8404
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Number of Children (Unduplicated) With at Least One Service 864
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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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6143 40696.570000 77484.6800 77484.6800
T 3261 23411.250000 39668.9700 39246.7400
4840 32565.320000 60758.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14244 96673.140000 177912.5500 116731.4200