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
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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 84.4600 42.2300
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 10 10.000000 510.5000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 18 22.000000 1153.3600 52.4255
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 90 101.500000 5075.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 5 2.250000 56.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 73 112.750000 5637.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 7 4.500000 112.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 71 208.750000 10437.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 5.250000 262.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 44 62.000000 3100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 25 65.500000 3275.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 428 3361.000000 33610.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 45 173.500000 12394.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 26 111.000000 6349.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 19 89.500000 6308.1600 70.4822
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 300.750000 21357.7400 71.0149
TRAV-TRAVS-Travel by mile 292 25388.00000 11299.4200 0.4451
Subtotal (Total Children Is Unduplicated) 450 29988.75000 119331.1100 3.9792
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Total 30010.750000 120484.4700 4.0147
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Number of Children (Unduplicated) With at Least One Service 450
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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 3 3.000000 110.0000 110.0000
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 3291 29999.750000 120321.3500 120321.3500
3 8.000000 53.1200 53.1200
Other 0 0.000000 0.0000 0.0000
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Total 3297 30010.750000 120484.4700 120484.4700