CMS/EIP Fiscal Report Center: 57
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
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 14 20.000000 1021.0000 51.0500
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 4.750000 237.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 50 51.000000 2550.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 89 91.000000 4550.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 22 28.250000 1412.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 47 47.000000 2350.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 149 150.000000 7500.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 75 461.000000 23050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 15 77.000000 3850.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 779 5734.000000 57340.0000 10.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 1 0.500000 35.7200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 8.000000 457.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 15.000000 1071.6000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 23.000000 1314.6800 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 9.000000 514.4400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 21.000000 1500.2400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 22.000000 1571.6800 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 6 28.750000 1063.7500 37.0000
TRAV-TRAVS-Travel by mile 9 2348.000000 1044.8400 0.4450
Subtotal (Total Children Is Unduplicated) 843 9122.750000 111548.4900 12.2275
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Total 9142.750000 112569.4900 12.3124
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Number of Children (Unduplicated) With at Least One Service 849
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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 3 4.000000 40.0000 40.0000
H 0 0.000000 0.0000 0.0000
T 2361 9138.750000 112529.4900 112519.4900
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2364 9142.750000 112569.4900 112559.4900