CMS/EIP Fiscal Report Center: 55
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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 50.000000 3750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 37 72.500000 5437.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 18.000000 999.0000 55.5000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 204.2000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 81 163.500000 11680.9000 71.4428
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 8.000000 200.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 177 973.000000 48650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 53 244.500000 17467.0800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 66 333.500000 19076.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 51 214.750000 15341.7400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 31 160.000000 9145.6000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 122 665.500000 47543.3200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 9.000000 124.9200 13.8800
Subtotal (Total Children Is Unduplicated) 385 2608.250000 157548.8600 60.4040
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Total 2771.750000 169229.7600 61.0552
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Number of Children (Unduplicated) With at Least One Service 431
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Center 55
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
2994 2771.750000 169229.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2994 2771.750000 169229.7600 0.0000