CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 Page: 1
List order: No List
Agency Filter:EXT
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
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
Subtotal (Total Children Is Unduplicated) 7 13.500000 1012.5000 75.0000
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 15 23.000000 1150.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 3.000000 150.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 94 396.000000 19800.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 53.000000 3786.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 14 35.000000 2500.4000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 157.000000 11158.8800 71.0757
TRAV-TRAVS-Travel by mile 322 15425.00000 6832.3500 0.4429
Subtotal (Total Children Is Unduplicated) 340 16098.00000 45652.9500 2.8359
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Total 16111.500000 46665.4500 2.8964
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Number of Children (Unduplicated) With at Least One Service 345
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Center 09
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 679 15823.500000 45898.7400 45898.7400
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
11 288.000000 766.7100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 690 16111.500000 46665.4500 45898.7400