CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 2 4.000000 200.0000 50.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 14.543000 1090.7200 74.9997
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 28.041800 2103.1300 74.9998
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 27.091600 2031.8700 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 11.000000 561.5500 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 1.510300 77.1000 51.0495
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 54 106.186700 7175.6700 67.5760
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 1.750000 87.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 5 5.000000 125.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 40 38.000000 1900.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 40 48.000000 1200.0000 25.0000
CONOP-CONOP-CONSULT, OT, PHONE 18 21.000000 525.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 39 37.500000 1875.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 12 16.500000 412.5000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 28.000000 700.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 83 530.000000 26500.0000 50.0000
INTR-T1013-INTERPRETER 3 10.000000 435.4200 43.5420
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 627 5364.000000 53640.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 65 284.781582 20344.7100 71.4397
OCCT-97530HM-OT SESSION BY OT ASST 29 155.262931 8881.0400 57.2000
PHY-97110-PT SESSION BY LICENSED PT 42 228.931142 16354.7699 71.4397
PHY-97110HM-PT SESSION BY PT ASST 19 92.442180 5283.9900 57.1599
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 151 865.724407 61847.3612 71.4400
TRAV-TRAVS-Travel by mile 66 2172.000000 967.0500 0.4452
Subtotal (Total Children Is Unduplicated) 657 9898.892242 201079.3411 20.3133
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Total 10005.078942 208255.0111 20.8149
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Number of Children (Unduplicated) With at Least One Service 671
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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 8480 10005.078942 208255.0111 208255.0100
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8480 10005.078942 208255.0111 208255.0100