CMS/EIP Fiscal Report Center: 53
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:TPIN
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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 11.000000 638.2500 58.0227
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 15.000000 832.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 14.000000 1050.0000 75.0000
Subtotal (Total Children Is Unduplicated) 19 46.500000 3008.2500 64.6935
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 69 351.000000 17550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 35.749992 2553.9792 71.4400
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
TRAV-TRAVS-Travel by mile 2 6.000000 2.6800 0.4467
Subtotal (Total Children Is Unduplicated) 78 399.749992 20438.4192 51.1280
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Total 446.249992 23446.6692 52.5416
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Number of Children (Unduplicated) With at Least One Service 94
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Center 53
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 68 64.037512 3493.8600 3493.8600
T 44 47.000000 2578.9600 2578.9600
302 335.212480 17373.8492 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 414 446.249992 23446.6692 6072.8200