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
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
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
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 6.000000 450.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 18 33.500000 1859.2500 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 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 25 53.500000 3133.2300 58.5650
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 11.000000 555.1400 50.4673
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 16.500000 825.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 46 222.250000 11112.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 6 22.000000 1571.6800 71.4400
Subtotal (Total Children Is Unduplicated) 62 275.750000 14350.0800 52.0402
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Total 329.250000 17483.3100 53.1004
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Number of Children (Unduplicated) With at Least One Service 80
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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 122 131.640000 7030.2700 7030.2700
191 197.610000 10453.0400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 313 329.250000 17483.3100 7030.2700