CMS/EIP Fiscal Report Center: 57
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 2.000000 150.0000 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 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 25.500000 1415.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 22.000000 1650.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.000000 357.3500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 34 75.500000 4647.2500 61.5530
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 616 4049.000000 202450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 80.750000 5768.7800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 7.500000 429.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 14 38.500000 2750.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 12 41.000000 2343.5600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 43.750000 3125.5000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 11.500000 657.8000 57.2000
Subtotal (Total Children Is Unduplicated) 663 4272.000000 217525.0800 50.9188
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Total 4347.500000 222172.3300 51.1035
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Number of Children (Unduplicated) With at Least One Service 680
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Center 57
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 -100.0000 -100.0000
1286 4349.500000 222272.3300 222172.1700
Other 0 0.000000 0.0000 0.0000
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Total 1287 4347.500000 222172.3300 222072.1700