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:TPIN
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) 2 2.000000 23.0300 11.5150
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 42.2800 8.4560
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 17.1200 8.5600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 8.000000 199.0100 24.8763
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 37.1000 18.5500
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 13.500000 1012.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 25.000000 1387.5000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.666667 500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 19.500000 1082.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 24.241566 1818.0681 74.9980
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 1.000000 15.0000 15.0000
Subtotal (Total Children Is Unduplicated) 52 111.908233 6358.8581 56.8221
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 76 600.791000 30002.0500 49.9376
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
Subtotal (Total Children Is Unduplicated) 76 602.791000 30070.0500 49.8847
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Total 714.699233 36428.9081 50.9710
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Number of Children (Unduplicated) With at Least One Service 109
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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 31 30.553200 1527.6600 1527.6600
T 137 139.505000 6972.6700 6972.6700
546 544.641033 27928.5781 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 714 714.699233 36428.9081 8500.3300