CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 16.5200 8.2600
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 2 2.000000 18.1200 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 50.6200 25.3100
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.500000 412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 8.500000 471.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 12.000000 900.0000 75.0000
Subtotal (Total Children Is Unduplicated) 22 42.500000 2559.5100 60.2238
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 41 217.250000 10862.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 65.000000 4643.6000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 17.000000 1214.4800 71.4400
Subtotal (Total Children Is Unduplicated) 55 299.250000 16720.5800 55.8750
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Total 341.750000 19280.0900 56.4158
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Number of Children (Unduplicated) With at Least One Service 69
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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 72 72.250000 4538.1000 4538.1000
T 29 31.500000 1716.0400 1716.0400
228 238.000000 13025.9500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 329 341.750000 19280.0900 6254.1400