CMS/EIP Fiscal Report Center: 54
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) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 34.500000 1914.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
Subtotal (Total Children Is Unduplicated) 32 54.000000 3118.1100 57.7428
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 275.4700 68.8675
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 82 434.850000 21743.1500 50.0015
OCCT-97530-OT SESSION BY LICENSED OT 6 24.500000 1750.2800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 16.000000 1143.0400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 20.000000 1428.8000 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 96 500.350000 26354.6200 52.6724
-----------------------------------------------------------------------------------------------------------------------
Total 554.350000 29472.7300 53.1663
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 117
-----------------------------------------------------------------------------------------------------------------------
Center 54
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 192 196.150000 10275.0200 10275.0200
358 358.200000 19197.7100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 550 554.350000 29472.7300 10275.0200