CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 2 4.000000 261.0000 65.2500
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 20.500000 1025.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 36 33.500000 1675.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 11 10.750000 268.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 32 48.000000 2400.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 3 3.000000 150.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.250000 6.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 20 26.000000 1300.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 5 2.500000 125.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 19 53.500000 2675.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.750000 87.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 5 8.000000 400.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 346 1794.000000 17940.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 3.000000 215.8800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 0.750000 53.9700 71.9600
PHY-97110HM-PT SESSION BY PT ASST 1 7.000000 402.9200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 4.750000 341.8100 71.9600
TRAV-TRAVS-Travel by mile 203 10080.00000 4484.8900 0.4449
Subtotal (Total Children Is Unduplicated) 364 12100.75000 33689.4700 2.7841
-----------------------------------------------------------------------------------------------------------------------
Total 12104.750000 33950.4700 2.8047
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 364
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 1735 12092.750000 33497.5500 33472.5500
3 12.000000 452.9200 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1738 12104.750000 33950.4700 33522.5500