CMS/EIP Fiscal Report Center: 57
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
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 11 11.000000 561.5500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 11 11.000000 561.5500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 612.6000 51.0500
Subtotal (Total Children Is Unduplicated) 22 35.000000 1786.7500 51.0500
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 3.000000 150.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 90 90.000000 4500.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 194 194.000000 9700.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 163 1180.000000 59000.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1372 11314.00000 113140.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 51.000000 3643.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.500000 85.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 10 53.500000 3822.0400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 21.000000 1200.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 107.000000 7644.0800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.500000 85.8000 57.2000
TRAV-TRAVS-Travel by mile 37 10706.00000 4764.0300 0.4450
Subtotal (Total Children Is Unduplicated) 1383 23724.50000 207835.5500 8.7604
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Total 23759.500000 209622.3000 8.8227
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Number of Children (Unduplicated) With at Least One Service 1386
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Center 57
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 174 88.000000 6245.9400 6245.9400
H 0 0.000000 0.0000 0.0000
T 4300 23665.500000 202988.5000 202988.5100
6 6.000000 387.8600 387.8600
Other 0 0.000000 0.0000 0.0000
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Total 4480 23759.500000 209622.3000 209622.3100