CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 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) 13 15.000000 760.6500 50.7100
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 227.2000 227.2000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 174 221.000000 11050.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 6 3.750000 93.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 277 464.250000 23212.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 104 185.500000 9275.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 92 163.250000 8162.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 187 288.500000 14425.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 201 977.000000 48850.0000 50.0000
INTR-T1013-INTERPRETER 4 22.250000 1057.7500 47.5393
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 165 825.000000 8250.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 36.500000 2607.5600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 15 78.500000 5608.0400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 98.000000 7001.1200 71.4400
TRAV-TRAVS-Travel by mile 625 69028.00000 30708.7900 0.4449
Subtotal (Total Children Is Unduplicated) 675 72392.50000 170529.2100 2.3556
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Total 72407.500000 171289.8600 2.3656
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Number of Children (Unduplicated) With at Least One Service 675
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Center 03
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 2702 27006.750000 64911.5800 64911.5800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 327 2997.750000 7358.7000 7358.7000
T 818 7229.500000 17240.1600 17240.1600
3412 35173.500000 81779.4200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7259 72407.500000 171289.8600 89510.4400