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: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
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 56.4900 56.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 40.3500 13.4500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 53.6600 8.9433
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 28.9800 9.6600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 138.8500 23.1417
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 51.9500 17.3167
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 16.500000 1237.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 22.000000 1248.7500 56.7614
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 49.000000 2719.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 44.000000 3300.0000 75.0000
Subtotal (Total Children Is Unduplicated) 72 165.000000 9788.3700 59.3235
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 5.000000 3411.5200 682.3040
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 2.000000 100.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 2 2.000000 460.0000 230.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 120 1329.569500 66978.4750 50.3761
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 2.000000 20.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 307.608956 21890.1426 71.1622
OCCT-97530HM-OT SESSION BY OT ASST 5 24.000000 1372.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 6.000000 428.6400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SENS-V5264-EARMOLD 1 3.000000 54.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 16.000000 1143.0400 71.4400
TRAV-TRAVS-Travel by mile 3 34.000000 15.1400 0.4453
Subtotal (Total Children Is Unduplicated) 148 1734.178456 96005.9176 55.3610
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Total 1899.178456 105794.2876 55.7053
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Number of Children (Unduplicated) With at Least One Service 187
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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 5 2.008246 110.3400 110.3400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 644 617.143885 36586.1342 36586.1300
T 243 249.100476 14206.0400 14206.0400
984 1030.925849 54891.7734 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1876 1899.178456 105794.2876 50902.5100