CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2019 ending 06/30/2019 Date of Report:07/21/2019 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 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.000000 525.0000 75.0000
Subtotal (Total Children Is Unduplicated) 13 23.000000 1569.0000 68.2174
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.000000 2195.9000 731.9667
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 49 339.500000 16975.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 49.750000 3539.9000 71.1538
OCCT-97530HM-OT SESSION BY OT ASST 5 24.000000 1372.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 6.000000 428.6400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 5.000000 357.2000 71.4400
TRAV-TRAVS-Travel by mile 1 28.000000 12.4600 0.4450
Subtotal (Total Children Is Unduplicated) 67 457.250000 24949.0600 54.5633
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Total 480.250000 26518.0600 55.2172
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Number of Children (Unduplicated) With at Least One Service 77
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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 29 30.000000 2726.3400 2726.3400
T 0 0.000000 0.0000 0.0000
407 450.250000 23791.7200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 436 480.250000 26518.0600 2726.3400