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
Payclass Filters:GR
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
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.500000 249.7500 55.5000
Subtotal (Total Children Is Unduplicated) 3 5.500000 277.5800 50.4691
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EI Services,Class #03
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-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 15 63.500000 3175.0000 50.0000
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 1 2.000000 142.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 3 12.000000 857.2800 71.4400
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) 80 1672.500000 6967.9900 4.1662
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Total 1678.000000 7245.5700 4.3180
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Number of Children (Unduplicated) With at Least One Service 83
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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 49 87.000000 2446.9100 2446.9100
210 1591.000000 4798.6600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 259 1678.000000 7245.5700 2446.9100