CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 12.500000 937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 75.000000 4162.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 43.000000 3225.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 80 145.500000 9324.9500 64.0890
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 337 2400.750000 119988.5000 49.9796
PHY-97110-PT SESSION BY LICENSED PT 14 69.000000 4929.3600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 31.000000 2214.6400 71.4400
Subtotal (Total Children Is Unduplicated) 352 2500.750000 127132.5000 50.8377
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Total 2646.250000 136457.4500 51.5663
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Number of Children (Unduplicated) With at Least One Service 393
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Center 54
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 0 0.000000 0.0000 0.0000
2624 2646.250000 136457.4500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2624 2646.250000 136457.4500 0.0000