CMS/EIP Fiscal Report Center: 55
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.066667 80.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 51.429470 3857.2100 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 45.968267 3447.6200 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 18.466667 1385.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 8.727522 445.5400 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 64 148.658593 10444.2200 70.2564
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EI Services,Class #03
AUD-92592TS-AUDIOLOGY SERVICES (Monaural) 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 3.000000 150.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 10.000000 500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 50 260.112127 18582.2300 71.4393
OCCT-97530HM-OT SESSION BY OT ASST 50 272.815949 15605.0800 57.2000
PHY-97110-PT SESSION BY LICENSED PT 34 215.847370 15420.1300 71.4400
PHY-97110HM-PT SESSION BY PT ASST 16 72.893896 4166.6100 57.1599
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 102 707.593614 50550.5000 71.4400
Subtotal (Total Children Is Unduplicated) 181 1544.262956 105074.5500 68.0419
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Total 1692.921549 115518.7700 68.2363
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Number of Children (Unduplicated) With at Least One Service 200
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Center 55
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 714 661.255200 45541.3900 45541.3900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 408 365.250000 24990.3500 24990.3500
817 664.416349 44837.0300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1940 1692.921549 115518.7700 70531.7400