CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 15.500000 1162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 36.000000 1998.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.500000 1162.5000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 48 81.000000 5193.0500 64.1117
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 13.000000 650.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 2 8.000000 551.1300 68.8913
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 15.000000 1033.6000 68.9067
Subtotal (Total Children Is Unduplicated) 14 38.000000 2349.0500 61.8171
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Total 119.000000 7542.1000 63.3790
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Number of Children (Unduplicated) With at Least One Service 62
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Center 01
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 24 23.500000 1412.4000 1412.4000
D 48 62.000000 3676.6300 0.0000
S 18 28.000000 2100.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3 3.000000 214.3200 214.3200
3 2.500000 138.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 96 119.000000 7542.1000 1626.7200