CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 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
Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 13.500000 1012.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 28 52.000000 2886.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 48 94.500000 5705.4300 60.3749
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 342.0000 342.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 0.750000 37.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 1 1.000000 50.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.500000 12.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 3.000000 150.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 4 5.000000 250.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 0.250000 6.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 22 49.250000 2462.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 213 955.000000 47737.0000 49.9864
INTR-T1013-INTERPRETER 1 4.000000 300.0000 75.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 32 66.000000 660.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 9.750000 696.5400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 10 34.750000 2482.5400 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 11 23.000000 1643.1200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 19.000000 1357.3600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 7 8.000000 571.5200 71.4400
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 27 16.500000 610.5000 37.0000
TRAV-TRAVS-Travel by mile 30 1497.000000 666.0800 0.4449
Subtotal (Total Children Is Unduplicated) 261 2696.750000 60174.8500 22.3138
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Total 2791.250000 65880.2800 23.6024
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Number of Children (Unduplicated) With at Least One Service 293
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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 69 107.000000 3738.9100 3738.9100
1269 2684.250000 62141.3700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1338 2791.250000 65880.2800 3738.9100