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
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-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 2.500000 187.5000 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 4 7.000000 525.0000 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 5 9.000000 499.5000 55.5000
Subtotal (Total Children Is Unduplicated) 14 26.500000 1633.6100 61.6457
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1194.2800 1194.2800
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 73.000000 3650.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 17 51.000000 2550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 22.000000 1571.6800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.750000 125.0200 71.4400
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
Subtotal (Total Children Is Unduplicated) 34 153.750000 9276.9800 60.3381
-----------------------------------------------------------------------------------------------------------------------
Total 180.250000 10910.5900 60.5303
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 44
-----------------------------------------------------------------------------------------------------------------------
Center 53
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 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 22 22.000000 1100.0000 1100.0000
146 158.250000 9810.5900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 168 180.250000 10910.5900 1100.0000