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: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
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
Subtotal (Total Children Is Unduplicated) 4 10.000000 633.0000 63.3000
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 342.0000 342.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 21.000000 1050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 35 120.000000 6000.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 3 10.000000 714.4000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 5 13.000000 928.7200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
Subtotal (Total Children Is Unduplicated) 47 172.000000 9481.7600 55.1265
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Total 182.000000 10114.7600 55.5756
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Number of Children (Unduplicated) With at Least One Service 51
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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 20 20.000000 1292.0000 1292.0000
157 162.000000 8822.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 177 182.000000 10114.7600 1292.0000