CMS/EIP Fiscal Report Center: 54
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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 19.500000 1082.2500 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 10.000000 750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.500000 412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 60 100.000000 5550.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 25.500000 1912.5000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 97 162.500000 9833.3000 60.5126
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 7.360000 764.3700 103.8546
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 358 1962.250000 98072.5000 49.9796
OCCT-97530-OT SESSION BY LICENSED OT 6 26.000000 1857.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 9 46.000000 3286.2400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 368 2042.610000 104051.9900 50.9407
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Total 2205.110000 113885.2900 51.6461
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Number of Children (Unduplicated) With at Least One Service 422
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Center 54
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
2145 2205.110000 113885.2900 85228.7100
Other 0 0.000000 0.0000 0.0000
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Total 2145 2205.110000 113885.2900 85228.7100