CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 17.9200 17.9200
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 12.6100 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 8.2600 8.2600
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 34.9700 34.9700
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.6800 20.6800
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 26.000000 1841.7900 70.8381
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 43.500000 3208.5300 73.7593
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 11 44.000000 2200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 49 130.500000 8176.5100 62.6552
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 24 143.500000 9008.1600 62.7746
PHY-97110-PT SESSION BY LICENSED PT 41 311.000000 19539.6000 62.8283
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 79 664.000000 44009.5000 66.2794
Subtotal (Total Children Is Unduplicated) 127 1120.500000 72593.2600 64.7865
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Total 1251.000000 80769.7700 64.5642
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Number of Children (Unduplicated) With at Least One Service 169
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Center 09
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 191 581.500000 33874.0600 33874.0600
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 0 0.000000 0.0000 0.0000
219 617.500000 43063.9600 0.0000
Other 33 52.000000 3831.7500 0.0000
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Total 443 1251.000000 80769.7700 33874.0600