CMS/EIP Fiscal Report Center: 52
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
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 70.4000 70.4000
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
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-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 8 15.000000 983.5000 65.5667
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 80 82.250000 4112.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 86 121.750000 6087.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 4 2.750000 68.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 91 221.500000 11075.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.250000 6.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 13.000000 650.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 26 28.500000 1425.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 64.000000 3200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 528 3520.000000 35200.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 47.000000 3351.9400 71.3179
OCCT-97530HM-OT SESSION BY OT ASST 12 59.000000 3374.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 13 51.750000 3697.0200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 101.750000 7071.5600 69.4994
TRAV-TRAVS-Travel by mile 386 27658.00000 12305.6800 0.4449
Subtotal (Total Children Is Unduplicated) 566 31974.50000 91733.1600 2.8689
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Total 31989.500000 92716.6600 2.8983
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Number of Children (Unduplicated) With at Least One Service 567
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Center 52
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 1 0.250000 12.5000 12.5000
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 3485 31939.250000 92508.1400 92508.1400
9 50.000000 196.0200 196.0200
Other 0 0.000000 0.0000 0.0000
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Total 3495 31989.500000 92716.6600 92716.6600