CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 ending 06/30/2021 Date of Report:07/15/2021 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 5 5.000000 98.5500 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 27.7400 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 5.000000 45.4000 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 10 10.000000 278.3000 27.8300
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 38.4700 38.4700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 22.4000 22.4000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 305.2500 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 22 41.500090 3112.5067 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 16 29.500000 2212.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 30.500000 1692.7500 55.5000
Subtotal (Total Children Is Unduplicated) 72 143.500090 8713.0667 60.7182
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EI Services,Class #03
AUDE-V5160-DISPENSING FEE BINAURAL 3 3.000000 690.0000 230.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 47.000000 2350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 68 585.000000 29250.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 13 104.500000 7465.4800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 3.000000 214.3200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 11 147.000034 10501.6822 71.4400
SENS-V5264-EARMOLD 2 5.000000 90.0000 18.0000
Subtotal (Total Children Is Unduplicated) 99 894.500034 50561.4822 56.5249
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Total 1038.000124 59274.5489 57.1046
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Number of Children (Unduplicated) With at Least One Service 158
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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 491 498.039436 27414.4675 27414.4700
503 539.960688 31860.0814 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 994 1038.000124 59274.5489 27414.4700