CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2022 ending 06/30/2022 Date of Report:08/08/2022 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 2 2.500000 92.5000 37.0000
Subtotal (Total Children Is Unduplicated) 2 2.500000 92.5000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 57.4400 28.7200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.7100 13.7100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.8900 20.8900
AUDE-92652-AEP THRSHLD EST MLT FREQ I&R 1 1.000000 74.6000 74.6000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
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 29 54.500000 4087.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 30.500000 1692.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 69 119.500000 6632.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 132 236.000000 14430.1400 61.1447
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 2413.4700 1206.7350
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 4.750000 237.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 8.000000 400.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 6 8.000000 400.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.000000 50.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 232 909.500000 45475.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 227 914.000000 45700.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 246 946.000000 9460.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 31.000000 2214.6400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.750000 125.0200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 11 39.500000 2821.8800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 10 40.000000 2857.6000 71.4400
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 32 26.000000 962.0000 37.0000
TRAV-TRAVS-Travel by mile 239 14497.00000 6449.2100 0.4449
Subtotal (Total Children Is Unduplicated) 371 17436.50000 119852.3200 6.8736
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Total 17675.000000 134374.9600 7.6025
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Number of Children (Unduplicated) With at Least One Service 456
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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 891 6217.500000 13648.5100 13648.5100
3117 11457.500000 120726.4500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4008 17675.000000 134374.9600 13648.5100