CMS/EIP Fiscal Report Center: 52
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 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 42.000000 3150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 37 72.000000 5256.3000 73.0042
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 126 700.000000 35000.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 80.500000 5750.9200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 5 28.000000 1601.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 16 60.750000 4339.9800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 322.750000 23057.2600 71.4400
Subtotal (Total Children Is Unduplicated) 207 1192.000000 69749.7600 58.5149
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Total 1264.000000 75006.0600 59.3402
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Number of Children (Unduplicated) With at Least One Service 228
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Center 52
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 1 2.000000 142.8800 142.8800
566 1262.000000 74863.1800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 567 1264.000000 75006.0600 142.8800