CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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
EVAL-96111-DEVELOPMENTAL EVALUATION 3 3.500000 175.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 3 4.000000 200.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 14.529667 1089.7200 74.9997
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 16.303866 1222.7800 74.9994
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 25.266667 1895.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 102.1000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 38 77.600200 5323.9000 68.6068
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 4.000000 1820.8700 455.2175
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 3.500000 175.0000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 2 4.000000 200.0000 50.0000
CONIP-CONIP-CONSULT, PHONE 20 37.500000 937.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 31 166.750000 8337.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 545 4670.000000 46700.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 63 329.948966 23571.5400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 10 45.003118 2574.1600 57.1996
PHY-97110-PT SESSION BY LICENSED PT 65 315.555455 22543.2500 71.4399
PHY-97110HM-PT SESSION BY PT ASST 8 36.650100 2094.9200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 179 1017.687473 72703.4900 71.4399
TRAV-TRAVS-Travel by mile 71 3570.000000 1589.1900 0.4452
Subtotal (Total Children Is Unduplicated) 569 10200.59511 183247.4200 17.9644
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Total 10278.195312 188571.3200 18.3467
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Number of Children (Unduplicated) With at Least One Service 577
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Center 55
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 7438 10255.762512 186950.5100 186950.5400
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 0 0.000000 0.0000 0.0000
40 22.432800 1620.8100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7478 10278.195312 188571.3200 186950.5400