CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:OTHER
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
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 3 4.000000 213.1000 53.2750
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.750000 87.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 12.500000 625.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 4.000000 40.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 4.000000 285.7600 71.4400
TRAV-TRAVS-Travel by mile 1 19.000000 8.4600 0.4453
Subtotal (Total Children Is Unduplicated) 23 54.250000 1778.9200 32.7912
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Total 58.250000 1992.0200 34.1978
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Number of Children (Unduplicated) With at Least One Service 26
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Center 52
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 4 22.000000 139.9000 124.9000
33 36.250000 1852.1200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 37 58.250000 1992.0200 124.9000