CMS/EIP Fiscal Report Center: 53
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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 17.000000 1275.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 34.000000 1887.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 54 90.500000 5022.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 45.000000 3375.0000 75.0000
Subtotal (Total Children Is Unduplicated) 90 199.000000 12497.2500 62.8003
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 297 1819.500000 90975.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 22.000000 1571.6800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
Subtotal (Total Children Is Unduplicated) 302 1844.500000 92653.8800 50.2325
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Total 2043.500000 105151.1300 51.4564
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Number of Children (Unduplicated) With at Least One Service 354
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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
1963 2043.500000 105151.1300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1963 2043.500000 105151.1300 0.0000