CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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-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-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 9 19.500000 1033.4000 52.9949
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 5.000000 215.1600 43.0320
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 2.250000 112.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 202 205.000000 10250.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 64 38.000000 1900.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 40 29.500000 1475.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.250000 12.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 88.000000 4400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 476 2134.000000 21340.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 3.000000 214.3200 71.4400
TRAV-TRAVS-Travel by mile 419 28701.00000 12768.1200 0.4449
Subtotal (Total Children Is Unduplicated) 478 31207.50000 52725.1000 1.6895
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Total 31227.000000 53758.5000 1.7215
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Number of Children (Unduplicated) With at Least One Service 478
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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 0 0.000000 0.0000 0.0000
T 2693 17537.500000 31553.1700 31553.1700
1883 13689.500000 22205.3300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4576 31227.000000 53758.5000 31553.1700