CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2019 ending 03/31/2019 Date of Report:05/04/2019 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-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.7100 19.7100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 1.000000 55.5000 55.5000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 9.000000 675.0000 75.0000
Subtotal (Total Children Is Unduplicated) 13 21.000000 1297.2400 61.7733
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 331.9200 331.9200
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 6.500000 325.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 5 2.000000 50.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 188 204.000000 10200.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 7 3.500000 87.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 13 8.500000 425.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 20 28.000000 1300.0000 46.4286
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 28 117.750000 5887.5000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 70.0000 35.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 514 2524.000000 25230.0000 9.9960
OCCT-97530-OT SESSION BY LICENSED OT 4 13.000000 928.7200 71.4400
TRAV-TRAVS-Travel by mile 467 41723.00000 18563.8300 0.4449
Subtotal (Total Children Is Unduplicated) 516 44633.25000 63399.4700 1.4205
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Total 44654.250000 64696.7100 1.4488
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Number of Children (Unduplicated) With at Least One Service 516
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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 641 4084.500000 7970.5200 7970.5200
T 1817 13745.000000 21748.7100 21748.7100
2828 26824.750000 34977.4800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5286 44654.250000 64696.7100 29719.2300