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
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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.392800 929.4600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.845800 888.4300 74.9996
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 75.000000 5625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 28.000000 1554.0000 55.5000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 65 137.238600 9507.3900 69.2764
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 58 321.750000 16087.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 56 281.750000 20128.2200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 28 145.750000 8336.9000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 53 251.470100 17965.0200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 16 71.000000 4058.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 197 1080.000000 77155.2000 71.4400
Subtotal (Total Children Is Unduplicated) 326 2151.720100 143731.2000 66.7983
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Total 2288.958700 153238.5900 66.9469
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Number of Children (Unduplicated) With at Least One Service 370
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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
2600 2288.958700 153238.5900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2600 2288.958700 153238.5900 0.0000