CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 7 10.500000 715.6500 68.1571
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 21 51.000000 2550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 11.000000 785.8400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 4 19.760000 1410.9400 71.4038
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 147.000000 10501.6800 71.4400
Subtotal (Total Children Is Unduplicated) 64 228.760000 15248.4600 66.6570
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Total 239.260000 15964.1100 66.7229
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Number of Children (Unduplicated) With at Least One Service 68
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Center 07
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 127 239.260000 15964.1100 15964.1100
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 127 239.260000 15964.1100 15964.1100