CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 13.8700 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 55.6600 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
Subtotal (Total Children Is Unduplicated) 6 12.500000 500.5600 40.0448
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 2.750000 137.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 6 7.750000 387.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 2.000000 100.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 17.000000 850.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 20 95.000000 4750.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 150.0000 75.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 38 95.000000 950.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 6.000000 428.6400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 17 13.750000 508.7500 37.0000
TRAV-TRAVS-Travel by mile 36 1604.000000 713.5300 0.4448
Subtotal (Total Children Is Unduplicated) 84 1853.250000 9368.8000 5.0553
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Total 1865.750000 9869.3600 5.2898
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Number of Children (Unduplicated) With at Least One Service 89
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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 70 70.500000 3395.3100 3395.3100
283 1795.250000 6474.0500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 353 1865.750000 9869.3600 3395.3100