CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Payclass Filters:TPIN
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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 38.306233 2872.9500 74.9995
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 7.850734 588.7900 74.9981
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 14.733333 1105.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 28 71.890300 5271.9900 73.3338
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EI Services,Class #03
CONIP-CONIP-CONSULT, PHONE 1 1.000000 25.0000 25.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 108.801634 7773.7600 71.4489
OCCT-97530HM-OT SESSION BY OT ASST 8 21.247282 1215.3400 57.1998
PHY-97110-PT SESSION BY LICENSED PT 14 58.475116 4177.4558 71.4399
PHY-97110HM-PT SESSION BY PT ASST 7 11.849900 677.3400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 114.064827 8148.7296 71.4395
Subtotal (Total Children Is Unduplicated) 65 315.438759 22017.6254 69.8000
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Total 387.329059 27289.6154 70.4559
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Number of Children (Unduplicated) With at Least One Service 87
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Center 55
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
540 387.329059 27289.6154 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 540 387.329059 27289.6154 0.0000