CMS/EIP Fiscal Report Center: 54
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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 29.500000 1637.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 14.500000 1087.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 103 172.000000 9546.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 15.000000 1125.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 140 248.500000 14684.3000 59.0918
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 2 2.000000 146.6400 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 490 3172.250000 158612.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 31.000000 2214.6400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 6.000000 343.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 13 41.000000 2929.0400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 11.000000 785.8400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 4 8.000000 111.0400 13.8800
Subtotal (Total Children Is Unduplicated) 510 3272.250000 165167.9000 50.4753
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Total 3520.750000 179852.2000 51.0835
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Number of Children (Unduplicated) With at Least One Service 566
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Center 54
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
3451 3520.750000 179852.2000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3451 3520.750000 179852.2000 0.0000