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:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 4 5.000000 303.1500 60.6300
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 9.000000 450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 12.250000 875.1400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 4 27.000000 1544.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 7 43.000000 3071.9200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 8.500000 485.8600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 13.500000 964.4400 71.4400
Subtotal (Total Children Is Unduplicated) 12 113.250000 7391.7600 65.2694
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Total 118.250000 7694.9100 65.0732
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Number of Children (Unduplicated) With at Least One Service 14
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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 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
133 118.250000 7694.9100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 133 118.250000 7694.9100 0.0000