CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2016 ending 06/30/2017 Date of Report:08/05/2017 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
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) 1 1.000000 8.2600 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 18.5500 18.5500
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 22 43.000000 3225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 28.000000 2100.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 72 139.000000 7623.5000 54.8453
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 18.000000 1350.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 16.500000 1237.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 91 166.000000 9213.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 133 226.000000 16950.0000 75.0000
WHEELO-97003TG-WHEELCHAIR EVAL/ FITTING BY LICENSED O 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 291 642.000000 41898.4200 65.2623
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 564 8046.750000 402176.0000 49.9799
Subtotal (Total Children Is Unduplicated) 564 8050.750000 402276.0000 49.9675
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Total 8692.750000 444174.4200 51.0971
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Number of Children (Unduplicated) With at Least One Service 714
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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 1 2.000000 20.0000 20.0000
8443 8690.750000 444154.4200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8444 8692.750000 444174.4200 20.0000