CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 13.8700 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.1600 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.9600 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
Subtotal (Total Children Is Unduplicated) 12 20.500000 934.6100 45.5907
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 49.4300 49.4300
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 8 6.500000 325.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 0.750000 18.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 216 260.500000 13025.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 8 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.250000 12.5000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 29 108.000000 5400.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 140.0000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 584 3009.000000 30080.0000 9.9967
OCCT-97530-OT SESSION BY LICENSED OT 1 0.750000 53.5800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 9.000000 642.9600 71.4400
TRAV-TRAVS-Travel by mile 534 45427.00000 20220.5900 0.4451
Subtotal (Total Children Is Unduplicated) 585 48827.75000 70042.8100 1.4345
-----------------------------------------------------------------------------------------------------------------------
Total 48848.250000 70977.4200 1.4530
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 586
-----------------------------------------------------------------------------------------------------------------------
Center 53
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 0 0.000000 0.0000 0.0000
H 2186 15591.250000 24784.2500 24784.2500
T 3396 28755.500000 38073.8100 38073.8100
602 4501.500000 8119.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6184 48848.250000 70977.4200 62858.0600