CMS/EIP Fiscal Report Center: 57
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
Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 29.000000 1480.4500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 40 41.000000 2093.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 61 88.000000 4392.8600 49.9189
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.500000 175.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 71 77.000000 3850.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 69 72.000000 3600.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 11 11.000000 550.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 48 48.000000 2400.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 132 135.000000 6750.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 10 253.000000 6325.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1005 8553.500000 427675.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 86 482.000000 24100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1012 9028.000000 90280.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 26 119.250000 8519.2200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 5 17.500000 1250.2000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 44 143.000001 8179.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 8 13.000000 928.7200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 14.000035 1000.1600 71.4398
PHY-97110HM-PT SESSION BY PT ASST 33 197.000000 11260.5200 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 5.000000 285.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 45 210.250015 15020.2600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 14.500000 1035.8800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 32 112.000000 6406.4000 57.2000
TRAV-TRAVS-Travel by mile 17 3014.000000 1341.1900 0.4450
Subtotal (Total Children Is Unduplicated) 1108 22525.50005 621057.9500 27.5713
-----------------------------------------------------------------------------------------------------------------------
Total 22613.500051 625450.8100 27.6583
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1124
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 8 3.140472 219.4300 219.4300
D 0 0.000000 0.0000 0.0000
S 20 23.000000 1007.8500 1007.8500
H 0 0.000000 0.0000 0.0000
T 4109 15840.609579 287025.1500 286997.1500
1917 6688.750000 335821.3400 335984.1500
Other 33 58.000000 1377.0400 1377.0400
---------------------------------------------------------
Total 6087 22613.500051 625450.8100 625585.6200