CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
Subtotal (Total Children Is Unduplicated) 3 6.000000 372.0000 62.0000
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 28 31.500000 1575.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 61 62.250000 3112.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 13 9.500000 237.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 44 74.250000 3712.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 19 25.500000 1275.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 7 4.000000 100.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 48 70.250000 3512.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 24 20.750000 1037.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 15 13.250000 662.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 4 1.750000 87.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 34 38.250000 1912.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 15 14.000000 700.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 34.000000 1700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 9.500000 475.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 410 2820.000000 28200.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 8.000000 571.5200 71.4400
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 5.500000 392.9200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 10.000000 714.4000 71.4400
TRAV-TRAVS-Travel by mile 308 25950.00000 11546.2500 0.4449
Subtotal (Total Children Is Unduplicated) 463 29204.25000 61607.2900 2.1095
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Total 29210.250000 61979.2900 2.1218
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Number of Children (Unduplicated) With at Least One Service 465
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Center 52
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 2592 29167.500000 61903.9900 61903.9900
4 42.750000 75.3000 75.3000
Other 0 0.000000 0.0000 0.0000
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Total 2596 29210.250000 61979.2900 61979.2900