CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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
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 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 17 23.000000 1296.6500 56.3761
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 94 104.750000 5237.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 56 95.750000 4787.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 7 10.500000 262.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 74 126.250000 6312.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 20 21.000000 1050.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 4 1.750000 43.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 22 26.000000 1300.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 15 54.000000 2700.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 469 3450.000000 34480.0000 9.9942
OCCT-97530-OT SESSION BY LICENSED OT 49 201.000000 14359.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 21 144.750000 8279.7000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 28 131.000000 9258.6400 70.6766
PHY-97110HM-PT SESSION BY PT ASST 1 5.750000 328.6700 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 51 310.500000 22182.1200 71.4400
TRAV-TRAVS-Travel by mile 282 24956.00000 11107.0000 0.4451
Subtotal (Total Children Is Unduplicated) 487 29641.00000 121739.3200 4.1071
-----------------------------------------------------------------------------------------------------------------------
Total 29664.000000 123035.9700 4.1477
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 489
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 55.250000 78.5000 78.5000
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 3241 29547.250000 122809.7700 122814.7700
6 61.500000 147.7000 147.7000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3250 29664.000000 123035.9700 123040.9700