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
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-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 59.1300 19.7100
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.000000 55.4800 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 36.3200 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 194.8100 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 44.8000 22.4000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 22 40.500000 2247.7500 55.5000
Subtotal (Total Children Is Unduplicated) 39 76.500000 3703.4800 48.4115
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 293.3800 293.3800
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 2 8.000000 400.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 64 645.000000 32250.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 14 30.000000 300.0000 10.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 8 48.000000 3429.1200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
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) 180 1635.750000 43413.1400 26.5402
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Total 1713.750000 47172.1200 27.5257
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Number of Children (Unduplicated) With at Least One Service 208
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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 909 1177.250000 44963.9900 44963.9900
71 536.500000 2208.1300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 980 1713.750000 47172.1200 44963.9900