CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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 2 2.000000 39.4200 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 13.8700 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 27.2400 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 166.9800 27.8300
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 38.4700 38.4700
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 14.500000 1087.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
Subtotal (Total Children Is Unduplicated) 26 49.500000 2877.2300 58.1259
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 4.000000 200.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 33 171.000000 8550.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 7 29.000000 2071.7600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 31.000000 2214.6400 71.4400
Subtotal (Total Children Is Unduplicated) 48 235.000000 13036.4000 55.4740
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Total 284.500000 15913.6300 55.9354
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Number of Children (Unduplicated) With at Least One Service 72
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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 27 27.000000 1350.0000 1350.0000
241 257.500000 14563.6300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 268 284.500000 15913.6300 1350.0000