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
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
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 17.000000 1275.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 42 84.500000 4689.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 63 136.500000 8267.2900 60.5662
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EI Services,Class #03
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 0.750000 37.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 2 3.000000 150.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 1.750000 87.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 22 14.500000 725.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.500000 125.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 4 3.000000 150.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 3.000000 150.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 10 14.000000 700.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 39.500000 1975.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 190 837.750000 41887.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 21 68.750000 4911.5000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 11 26.250000 1875.3000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 11 48.000000 3429.1200 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 6.000000 428.6400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 8 9.250000 342.2500 37.0000
TRAV-TRAVS-Travel by mile 1 42.000000 18.6900 0.4450
Subtotal (Total Children Is Unduplicated) 266 1125.000000 57369.4400 50.9951
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Total 1261.500000 65636.7300 52.0307
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Number of Children (Unduplicated) With at Least One Service 311
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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 101 139.500000 4934.0200 4884.0200
1087 1122.000000 60702.7100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1188 1261.500000 65636.7300 4884.0200