CMS/EIP Fiscal Report Center: 09
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:OTHER
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 2 4.000000 200.0000 50.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 3 6.000000 300.0000 50.0000
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 9 12.250000 612.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 21 36.000000 1800.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 31 34.000000 850.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 5 6.000000 150.0000 25.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 10 15.000000 750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 180 959.000000 46909.0800 48.9146
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 37.000000 1850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 36 151.000000 10787.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 54 324.000000 23146.5600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 67.000000 4786.4800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 105 768.500000 54901.6400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 14 82.000000 5858.0800 71.4400
TRAV-TRAVS-Travel by mile 552 43696.00000 19279.2500 0.4412
Subtotal (Total Children Is Unduplicated) 651 46196.75000 172152.4700 3.7265
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Total 46202.750000 172452.4700 3.7325
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Number of Children (Unduplicated) With at Least One Service 652
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Center 09
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 1946 46202.750000 172452.4700 172452.4700
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1946 46202.750000 172452.4700 172452.4700