CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 ending 09/30/2020 Date of Report:10/15/2020 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
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
Subtotal (Total Children Is Unduplicated) 5 8.000000 438.5000 54.8125
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 0.750000 37.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 2 3.000000 150.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 1.750000 87.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 22 14.500000 725.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.500000 125.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 4 3.000000 150.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 3.000000 150.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 10 14.000000 700.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 6.000000 300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 19 89.750000 4487.5000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 4 17.000000 1214.4800 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 8 9.250000 342.2500 37.0000
TRAV-TRAVS-Travel by mile 1 42.000000 18.6900 0.4450
Subtotal (Total Children Is Unduplicated) 77 209.500000 8562.9200 40.8731
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Total 217.500000 9001.4200 41.3858
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Number of Children (Unduplicated) With at Least One Service 81
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Center 53
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 81 119.500000 3934.0200 3884.0200
115 98.000000 5067.4000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 196 217.500000 9001.4200 3884.0200