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:MED
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
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 16 27.500000 2062.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 18.500000 1387.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 24 46.500000 2580.7500 55.5000
Subtotal (Total Children Is Unduplicated) 48 96.500000 6228.2900 64.5419
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 40.000000 2000.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 176 875.000000 43750.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 9 30.250000 2161.0600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 2.750000 196.4600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 13 40.000000 2857.6000 71.4400
Subtotal (Total Children Is Unduplicated) 205 989.000000 51036.5600 51.6042
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Total 1085.500000 57264.8500 52.7544
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Number of Children (Unduplicated) With at Least One Service 247
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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 0 0.000000 0.0000 0.0000
1044 1085.500000 57264.8500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1044 1085.500000 57264.8500 0.0000