CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:GR
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-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 27.7400 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 22.4000 22.4000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
Subtotal (Total Children Is Unduplicated) 5 12.000000 439.7600 36.6467
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.500000 125.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 1 0.250000 12.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 2 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 35 157.750000 7887.5000 50.0000
Subtotal (Total Children Is Unduplicated) 42 167.500000 8375.0000 50.0000
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Total 179.500000 8814.7600 49.1073
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Number of Children (Unduplicated) With at Least One Service 45
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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 97 96.000000 4606.7600 4606.7600
80 83.500000 4208.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 177 179.500000 8814.7600 4606.7600