CMS/EIP Fiscal Report Center: 57
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
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 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 13 13.000000 663.6500 51.0500
Subtotal (Total Children Is Unduplicated) 31 50.000000 2893.3000 57.8660
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 8.000000 200.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 588 4610.000000 230500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 51.318300 3666.1800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 16 55.500000 3964.9200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 39.750000 2272.1100 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 20.750000 1482.3800 71.4400
Subtotal (Total Children Is Unduplicated) 617 4787.318300 242199.9900 50.5920
-----------------------------------------------------------------------------------------------------------------------
Total 4837.318300 245093.2900 50.6672
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 627
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 2 6.000000 428.6400 428.6400
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 2 6.000000 300.0000 300.0000
1353 4825.318300 244364.6500 244364.6500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1357 4837.318300 245093.2900 245093.2900