CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2018 ending 09/30/2018 Date of Report:11/06/2018 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-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-92568-ACOUSTIC REFLEX TESTING (MEMR) 1 1.000000 9.0600 9.0600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 25.3100 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 18.5500 18.5500
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 12.500000 693.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 16.000000 1200.0000 75.0000
Subtotal (Total Children Is Unduplicated) 19 37.500000 2228.5400 59.4277
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 209.000000 10450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 80.729560 5767.3196 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 8.000000 571.5200 71.4400
Subtotal (Total Children Is Unduplicated) 58 298.729560 16813.8396 56.2845
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Total 336.229560 19042.3796 56.6351
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Number of Children (Unduplicated) With at Least One Service 72
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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 2 1.088400 54.4200 54.4200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 10.500000 436.2900 436.2900
T 2 3.000000 161.0000 161.0000
314 321.641160 18390.6696 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 327 336.229560 19042.3796 651.7100