CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:OTHER
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-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 1 1.000000 51.0500 51.0500
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 10.000000 500.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 28.000000 1400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 45 99.000000 990.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.500000 107.1600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 1.500000 107.1600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 6.500000 464.3600 71.4400
Subtotal (Total Children Is Unduplicated) 50 147.500000 3618.6800 24.5334
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Total 148.500000 3669.7300 24.7120
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Number of Children (Unduplicated) With at Least One Service 50
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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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 100 148.500000 3669.7300 3669.7300
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Total 100 148.500000 3669.7300 3669.7300