CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 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 9 9.000000 177.3900 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 6.000000 83.2200 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 9.000000 81.7200 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 18 18.000000 500.9400 27.8300
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 38.4700 38.4700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 33.4000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.000000 67.2000 22.4000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 11 17.000000 1275.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 12 22.000000 1650.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 22 41.500000 2303.2500 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 83 150.000090 11250.0067 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 76 139.000000 10425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 194 372.000000 20646.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
Subtotal (Total Children Is Unduplicated) 401 819.500090 50490.5867 61.6114
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 293.3800 293.3800
AUDE-V5160-DISPENSING FEE BINAURAL 3 3.000000 690.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 8.500000 425.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 10 7.750000 387.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 2.000000 50.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 5 2.750000 137.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 25 21.750000 1087.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.500000 125.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 22 22.500000 1125.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 23 45.750000 2287.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 56 250.500000 12525.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 505 5914.750000 295737.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14 30.000000 300.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 36 254.750000 18199.3400 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 3 8.000000 571.5200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 16 49.500000 3536.2800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 4.000000 285.7600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 32 310.000034 22146.4022 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 6.000000 428.6400 71.4400
SENS-V5264-EARMOLD 2 5.000000 90.0000 18.0000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 9 10.250000 379.2500 37.0000
TRAV-TRAVS-Travel by mile 15 772.000000 343.5100 0.4450
Subtotal (Total Children Is Unduplicated) 636 7739.250034 361473.0222 46.7065
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Total 8560.250124 412019.1089 48.1317
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Number of Children (Unduplicated) With at Least One Service 886
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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 3 6.000000 372.0000 259.5000
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 1400 1675.289436 72378.4575 72378.4600
6116 6878.960688 339268.6514 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7519 8560.250124 412019.1089 72637.9600