CMS/EIP Fiscal Report Center: 55
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
EVAL-96111-DEVELOPMENTAL EVALUATION 6 12.000000 600.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 8 14.000000 700.0000 50.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.771467 132.8600 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.533333 265.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 11.538400 865.3800 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 11 21.819820 1211.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 0.539275 27.5300 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 43 84.202295 4940.0200 58.6685
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 2 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 6 5.000000 250.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 63 64.000000 1600.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 32 55.000000 2750.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 39 110.000000 2750.0000 25.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 3.500000 87.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 4 3.000000 150.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 52 44.000000 1100.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 9.000000 225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 69 401.000000 20050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 19 88.250000 4412.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 577 4589.000000 45890.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 27.324045 1952.0300 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 7 27.761711 1587.9700 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 3.315910 189.6700 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 4.443165 317.4200 71.4401
PHY-97110HM-PT SESSION BY PT ASST 4 21.361092 1221.0000 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 0.739678 42.2800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 130.526600 9324.8200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 49.678606 3549.0400 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 0.500000 18.5000 37.0000
TRAV-TRAVS-Travel by mile 68 3560.000000 1583.7300 0.4449
Subtotal (Total Children Is Unduplicated) 599 9201.400807 99251.4600 10.7866
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Total 9285.603102 104191.4800 11.2208
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Number of Children (Unduplicated) With at Least One Service 614
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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 0 0.000000 0.0000 0.0000
P 5286 7825.696282 89002.8900 89002.8900
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
842 1459.906820 15188.5900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6128 9285.603102 104191.4800 89002.8900