CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 46.500000 3487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 23.8600 23.8600
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 14.4300 14.4300
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 29 54.500000 3943.9400 72.3659
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1340.0000 1340.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 45.500000 3250.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 15 45.500000 1460.3100 32.0947
SENS-V5060-BEHIND EAR HEARING AID
1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 155.500000 11055.3200 71.0953
Subtotal (Total Children Is Unduplicated) 50 249.500000 17352.1500 69.5477
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Total 304.000000 21296.0900 70.0529
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Number of Children (Unduplicated) With at Least One Service 73
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Center 02
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 307 304.000000 21296.0900 21296.0900
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 307 304.000000 21296.0900 21296.0900