CMS/EIP Fiscal Report Center: 53
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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 16.000000 888.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 23.000000 1276.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 50.000000 3750.0000 75.0000
Subtotal (Total Children Is Unduplicated) 62 120.000000 8239.5000 68.6625
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 249 1361.000000 68001.0000 49.9640
Subtotal (Total Children Is Unduplicated) 249 1363.000000 68051.0000 49.9274
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Total 1483.000000 76290.5000 51.4434
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Number of Children (Unduplicated) With at Least One Service 294
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Center 53
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
1432 1483.000000 76290.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1432 1483.000000 76290.5000 0.0000