CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2021 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-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 23.5000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.5800 14.5800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 86.1600 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
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 19.500000 1462.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 30 55.500000 3080.2500 55.5000
Subtotal (Total Children Is Unduplicated) 51 97.000000 5741.6300 59.1921
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 4.000000 2620.4000 655.1000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 29 116.250000 5812.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 68 533.500000 26675.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 150.0000 75.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 36.000000 2571.8400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 6 16.000000 1143.0400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 4 10.000000 714.4000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 0.023665 1.6907 71.4431
SENS-V5264-EARMOLD 2 4.000000 72.0000 18.0000
Subtotal (Total Children Is Unduplicated) 97 724.773665 39910.8707 55.0667
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Total 821.773665 45652.5007 55.5536
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Number of Children (Unduplicated) With at Least One Service 134
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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 326 330.454800 16934.1200 16934.1200
455 491.318865 28718.3807 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 781 821.773665 45652.5007 16934.1200