CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 1.500000 55.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 1.500000 55.5000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 39.4200 19.7100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 111.3200 27.8300
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 21 38.000000 2850.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 14 26.000000 1950.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 34 64.500000 3579.7500 55.5000
Subtotal (Total Children Is Unduplicated) 70 137.500000 8689.5700 63.1969
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.000000 200.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 4 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 12 12.000000 600.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 8 10.500000 525.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 61.000000 3050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 213 1034.000000 51700.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12 23.000000 230.0000 10.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 11 40.250000 2875.4600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 2.750000 196.4600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 4.000000 285.7600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 18 57.000000 4072.0800 71.4400
TRAV-TRAVS-Travel by mile 12 607.000000 270.0900 0.4450
Subtotal (Total Children Is Unduplicated) 267 1859.500000 64204.8500 34.5280
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Total 1998.500000 72949.9200 36.5023
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Number of Children (Unduplicated) With at Least One Service 329
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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 132 314.000000 6383.4100 6383.4100
1227 1684.500000 66566.5100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1359 1998.500000 72949.9200 6383.4100