CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.250000 9.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.250000 9.2500 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.5800 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.7900 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.7200 28.7200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.8900 20.8900
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 15.000000 832.5000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 20 42.000000 3150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 24.000000 1800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 91 171.500000 9518.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
Subtotal (Total Children Is Unduplicated) 147 292.500000 17823.9800 60.9367
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 16 33.000000 1595.1900 48.3391
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 24.250000 1212.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 48 37.750000 1887.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 10 16.000000 800.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 13 23.500000 1175.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 6.250000 312.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 83 204.250000 10212.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 364 1964.500000 98225.0000 50.0000
INTR-T1013-INTERPRETER 8 42.750000 1693.7500 39.6199
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 54 155.000000 1550.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 30.000000 2143.2000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 21 94.000000 6715.3600 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 14.000000 1000.1600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 16 63.000000 4500.7200 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 6.000000 428.6400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 28 41.000000 1517.0000 37.0000
TRAV-TRAVS-Travel by mile 52 3967.000000 1765.1200 0.4450
Subtotal (Total Children Is Unduplicated) 476 6725.250000 136927.0200 20.3601
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Total 7018.000000 154760.2500 22.0519
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Number of Children (Unduplicated) With at Least One Service 561
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Center 54
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 576 2168.890000 23895.2200 23895.2200
2534 4849.110000 130865.0300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3110 7018.000000 154760.2500 23895.2200