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
Payclass Filters:GR
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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 14.500000 804.7500 55.5000
Subtotal (Total Children Is Unduplicated) 12 21.500000 1263.8300 58.7828
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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-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 16 71.000000 3550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12 23.000000 230.0000 10.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
TRAV-TRAVS-Travel by mile 12 607.000000 270.0900 0.4450
Subtotal (Total Children Is Unduplicated) 54 733.500000 5717.9700 7.7955
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Total 756.500000 7037.3000 9.3024
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Number of Children (Unduplicated) With at Least One Service 66
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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 101 283.000000 4885.8700 4885.8700
65 473.500000 2151.4300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 166 756.500000 7037.3000 4885.8700