CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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 7 14.000000 1050.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 36.500000 2025.7500 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 86.000000 4773.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 37.000000 2775.0000 75.0000
Subtotal (Total Children Is Unduplicated) 85 178.000000 10961.2500 61.5801
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 296 1585.250000 79262.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 3.000000 214.3200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 171.6000 57.2000
Subtotal (Total Children Is Unduplicated) 299 1591.250000 79648.4200 50.0540
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Total 1769.250000 90609.6700 51.2136
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Number of Children (Unduplicated) With at Least One Service 356
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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
1701 1769.250000 90609.6700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1701 1769.250000 90609.6700 0.0000