CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
Subtotal (Total Children Is Unduplicated) 5 9.500000 527.2500 55.5000
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 1.000000 50.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 1 1.000000 50.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 25 119.000000 5950.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 4.000000 40.0000 10.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 1 3.000000 214.3200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 3 63.000000 28.0300 0.4449
Subtotal (Total Children Is Unduplicated) 38 196.000000 6578.7900 33.5653
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Total 205.500000 7106.0400 34.5793
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Number of Children (Unduplicated) With at Least One Service 42
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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 56 55.500000 2786.0000 2786.0000
87 150.000000 4320.0400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 143 205.500000 7106.0400 2786.0000