CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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 27 42.250000 2112.5000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 31 48.750000 2546.8000 52.2421
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 11 11.750000 587.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 23 27.500000 1375.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 4.000000 100.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 60 95.250000 4762.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 94 240.500000 12025.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 49 77.250000 3862.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 3 4.750000 237.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 28 53.500000 2675.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 62 96.250000 4812.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 54.000000 2700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 4.000000 200.0000 50.0000
INTR-T1013-INTERPRETER 16 79.000000 3950.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 309 1998.000000 19980.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 5.250000 375.0600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 3.750000 267.9000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 22.750000 1625.2600 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 2 1.500000 55.5000 37.0000
TRAV-TRAVS-Travel by mile 132 11792.00000 5246.2900 0.4449
Subtotal (Total Children Is Unduplicated) 368 14574.00000 64937.5100 4.4557
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Total 14622.750000 67484.3100 4.6150
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Number of Children (Unduplicated) With at Least One Service 375
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Center 02
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 12 12.000000 160.0000 160.0000
H 0 0.000000 0.0000 0.0000
T 3107 12302.500000 65241.4000 65241.4000
135 2308.250000 2082.9100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3254 14622.750000 67484.3100 65401.4000