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
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 1 1.000000 51.0500 51.0500
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 3.000000 150.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 4.000000 40.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 28.5600 14.2800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 7.750000 553.6600 71.4400
TRAV-TRAVS-Travel by mile 5 31.000000 13.7800 0.4445
Subtotal (Total Children Is Unduplicated) 22 55.250000 1191.3800 21.5634
-----------------------------------------------------------------------------------------------------------------------
Total 56.250000 1242.4300 22.0876
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 23
-----------------------------------------------------------------------------------------------------------------------
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 0 0.000000 0.0000 0.0000
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 1 2.000000 28.5600 28.5600
28 54.250000 1213.8700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 29 56.250000 1242.4300 28.5600