CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2022 ending 09/30/2022 Date of Report:10/18/2022 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:GR
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 19.5100 19.5100
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 22.0700 22.0700
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.8900 20.8900
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 5 9.500000 464.8900 48.9358
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 1 0.250000 12.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 11.000000 550.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 35 146.500000 7325.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 15 50.500000 2525.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 275 919.000000 9190.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 7.000000 500.0800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 3.000000 214.3200 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 42 16.250000 601.2500 37.0000
TRAV-TRAVS-Travel by mile 276 16051.00000 7123.0900 0.4438
Subtotal (Total Children Is Unduplicated) 299 17210.50000 28341.2400 1.6467
-----------------------------------------------------------------------------------------------------------------------
Total 17220.000000 28806.1300 1.6728
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 303
-----------------------------------------------------------------------------------------------------------------------
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 1423 11868.500000 19171.4900 19171.4900
665 5351.500000 9634.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2088 17220.000000 28806.1300 19171.4900