CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2019 ending 06/30/2019 Date of Report:07/21/2019 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
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 19.7100 19.7100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 77.500000 4268.0000 55.0710
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 45.500000 3412.5000 75.0000
Subtotal (Total Children Is Unduplicated) 89 150.500000 9445.5400 62.7611
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 280 1621.750000 81087.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 75.500000 5372.2800 71.1560
OCCT-97530HM-OT SESSION BY OT ASST 5 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 16 74.000000 5286.5600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 8.000000 571.5200 71.4400
Subtotal (Total Children Is Unduplicated) 318 1789.250000 92793.1800 51.8615
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Total 1939.750000 102238.7200 52.7072
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Number of Children (Unduplicated) With at Least One Service 377
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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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1889 1939.750000 102238.7200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1889 1939.750000 102238.7200 0.0000