CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2018 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 22 40.500000 3037.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 39 78.000000 4329.0000 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 26 39.500000 2962.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 188 320.000000 17615.7500 55.0492
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 129 195.500000 14662.5000 75.0000
Subtotal (Total Children Is Unduplicated) 343 695.000000 44117.2900 63.4781
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 21.000000 525.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 552 7522.750000 376048.5000 49.9882
OCCT-97530-OT SESSION BY LICENSED OT 33 243.500000 17359.9600 71.2935
OCCT-97530HM-OT SESSION BY OT ASST 5 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 18 101.000000 7158.3200 70.8745
PHY-97110HM-PT SESSION BY PT ASST 3 5.000000 285.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 21.000000 1500.2400 71.4400
Subtotal (Total Children Is Unduplicated) 589 7919.250000 403163.8200 50.9093
-----------------------------------------------------------------------------------------------------------------------
Total 8614.250000 447281.1100 51.9234
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 764
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
8349 8614.250000 447281.1100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8349 8614.250000 447281.1100 0.0000