CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.1600 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 29.8800 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 55.6600 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 33.4000 16.7000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 10.500000 582.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 14 29.500000 1469.8500 49.8254
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 37 191.000000 9550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 84.750000 6040.3000 71.2720
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 3 14.500000 1035.8800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 18.000000 1285.9200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 58 310.250000 17983.1800 57.9635
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Total 339.750000 19453.0300 57.2569
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Number of Children (Unduplicated) With at Least One Service 70
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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 26 26.000000 1082.6100 1082.6100
308 313.750000 18370.4200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 334 339.750000 19453.0300 1082.6100