CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 ending 09/30/2020 Date of Report:10/15/2020 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 1 1.000000 19.7100 19.7100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
Subtotal (Total Children Is Unduplicated) 11 21.000000 1277.5400 60.8352
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EI Services,Class #03
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 6.000000 300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 22 87.000000 4350.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 10 35.000000 2500.4000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 37.000000 2643.2800 71.4400
Subtotal (Total Children Is Unduplicated) 41 166.000000 10023.6800 60.3836
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Total 187.000000 11301.2200 60.4343
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Number of Children (Unduplicated) With at Least One Service 51
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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 20 20.000000 1000.0000 1000.0000
160 167.000000 10301.2200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 180 187.000000 11301.2200 1000.0000