CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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-92550-TYMPANOMETRY & REFLEX THRESH 3 3.000000 47.5200 15.8400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 115.6800 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 27.6200 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
EXIT-EXIT-EXIT ASSESSMENT 4 8.000000 400.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 17.500000 1312.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 24.000000 1800.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 27.000000 1498.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 44 74.000000 4107.0000 55.5000
Subtotal (Total Children Is Unduplicated) 95 183.000000 10861.3600 59.3517
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 9.000000 9230.1000 1025.5667
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 4 2.000000 100.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 24 33.000000 1650.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 243 1142.000000 57000.0000 49.9124
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 184 431.000000 21550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 303 1338.000000 13380.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 36 158.000000 11369.6800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 14 26.000000 1849.0000 71.1154
OCCT-97530TL-OT SESSION BY LICENSED OT 15 39.000000 2806.4400 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 8 4.750000 175.7500 37.0000
TRAV-TRAVS-Travel by mile 298 18157.00000 8077.1200 0.4448
Subtotal (Total Children Is Unduplicated) 370 21344.75000 127457.0100 5.9714
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Total 21527.750000 138318.3700 6.4251
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Number of Children (Unduplicated) With at Least One Service 431
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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 1611 10800.750000 32870.5500 32870.5500
2976 10727.000000 105447.8200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4587 21527.750000 138318.3700 32870.5500