CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
Agency Filter:EXT
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
EVAL-96111-DEVELOPMENTAL EVALUATION 6 12.000000 600.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 5 10.000000 500.0000 50.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 22.000000 1650.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 100.000001 7500.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 140 285.999999 21450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 58 117.837600 8837.8200 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 96.000000 5328.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 31 31.000000 1582.5500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 21 27.000000 1378.3500 51.0500
Subtotal (Total Children Is Unduplicated) 309 732.837600 50501.6700 68.9125
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 5.000000 250.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 76 86.000000 4300.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 126 159.750000 3993.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 52 76.000000 3800.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 67 130.750000 3268.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 64 71.500000 3575.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 105 113.750000 2843.7500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 51.750000 1293.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 431 3015.000000 150750.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 835 7256.000000 72560.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 131 803.386195 57393.9100 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 167 934.125872 53432.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 69 433.460084 30948.5285 71.3988
PHY-97110HM-PT SESSION BY PT ASST 49 297.375259 16997.9700 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 262 1863.045492 133053.0900 71.4170
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 41.6400 13.8800
TRAV-TRAVS-Travel by mile 156 7908.000000 3517.9500 0.4449
Subtotal (Total Children Is Unduplicated) 860 23208.39290 542045.0885 23.3556
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Total 23941.230502 592546.7585 24.7501
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Number of Children (Unduplicated) With at Least One Service 966
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Center 55
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 1 2.000000 150.0000 0.0000
P 8193 14355.206999 169941.0600 169941.0600
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 0 0.000000 0.0000 0.0000
8631 9584.023503 422455.6985 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16825 23941.230502 592546.7585 169941.0600