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: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
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 25.0000 25.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 85.0400 42.5200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 246.8200 41.1367
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 9 14.500000 745.4100 51.4076
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 17.000000 850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 29.250000 1619.5600 55.3696
PHY-97110-PT SESSION BY LICENSED PT 11 56.500000 3817.1400 67.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 157.000000 7779.6600 49.5520
Subtotal (Total Children Is Unduplicated) 47 259.750000 14066.3600 54.1535
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Total 274.250000 14811.7700 54.0083
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Number of Children (Unduplicated) With at Least One Service 51
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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 0 0.000000 0.0000 0.0000
144 274.250000 14811.7700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 144 274.250000 14811.7700 0.0000