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:TPIN
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 3 3.000000 83.4900 27.8300
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
Subtotal (Total Children Is Unduplicated) 11 19.500000 1197.4500 61.4077
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 21.000000 1050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 23 88.000000 4400.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 2 8.000000 571.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 3.000000 214.3200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 17.000000 1214.4800 71.4400
Subtotal (Total Children Is Unduplicated) 36 137.000000 7450.3200 54.3819
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Total 156.500000 8647.7700 55.2573
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Number of Children (Unduplicated) With at Least One Service 46
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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 31 31.000000 1497.5400 1497.5400
118 125.500000 7150.2300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 149 156.500000 8647.7700 1497.5400