CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2019 ending 06/30/2020 Date of Report:07/21/2020 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-92552-PURE TONE AUDIOMETRY -AIR ONLY 4 4.000000 78.8400 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 2 2.000000 46.9800 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.000000 69.3500 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 7.000000 63.5600 9.0800
AUDE-92568-ACOUSTIC REFLEX TESTING (MEMR) 3 3.000000 29.8800 9.9600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 9.000000 250.4700 27.8300
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 38.4700 38.4700
AUDE-92585-AUD EVOKED RESPONSE (COMP) 2 2.000000 169.6800 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.000000 83.5000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 22.4000 22.4000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 19.000000 1425.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 36.000000 1998.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 17.500000 1312.5000 75.0000
Subtotal (Total Children Is Unduplicated) 66 139.500000 7396.1300 53.0189
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 89 849.000000 42450.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 36 135.000000 6750.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 206.750000 14755.9800 71.3711
OCCT-97530GT-OT SESSION BY LICENSED OT 7 41.000000 2929.0400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 12 71.500000 5086.5200 71.1401
PHY-97110GT-PT SESSION BY LICENSED PT 6 32.000000 2286.0800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 26.000000 1857.4400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 139 1365.250000 76286.1400 55.8770
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Total 1504.750000 83682.2700 55.6121
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Number of Children (Unduplicated) With at Least One Service 182
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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 579 575.034306 29975.7100 29725.7100
913 929.715694 53706.5600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1492 1504.750000 83682.2700 29725.7100