CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2022 ending 09/30/2022 Date of Report:10/18/2022 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 19.5100 19.5100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 14.4000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 115.6800 28.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 44.7600 44.7600
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 5 9.000000 675.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
Subtotal (Total Children Is Unduplicated) 13 22.500000 1203.8500 53.5044
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 17 59.250000 2962.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 14.000000 700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 7.750000 553.6600 71.4400
Subtotal (Total Children Is Unduplicated) 23 81.000000 4216.1600 52.0514
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Total 103.500000 5420.0100 52.3672
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Number of Children (Unduplicated) With at Least One Service 35
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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 14 14.000000 700.0000 700.0000
85 89.500000 4720.0100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 99 103.500000 5420.0100 700.0000