CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 33.500000 2512.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 24.000000 1800.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 509.4500 50.9450
Subtotal (Total Children Is Unduplicated) 46 83.500000 5974.0500 71.5455
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 124 803.750000 40187.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 103.750000 7387.5400 71.2052
OCCT-97530HM-OT SESSION BY OT ASST 7 26.000000 1487.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 17 89.250000 6376.0200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 308.000000 21813.5200 70.8231
Subtotal (Total Children Is Unduplicated) 195 1330.750000 77251.7800 58.0513
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Total 1414.250000 83225.8300 58.8480
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Number of Children (Unduplicated) With at Least One Service 216
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Center 52
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 1 2.000000 150.0000 150.0000
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 4.000000 200.0000 0.0000
609 1408.250000 82875.8300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 611 1414.250000 83225.8300 150.0000