CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2018 ending 09/30/2018 Date of Report:11/06/2018 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 7 13.500000 1012.5000 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 10 20.000000 1110.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 76.000000 4162.5000 54.7697
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 58.000000 4350.0000 75.0000
Subtotal (Total Children Is Unduplicated) 83 185.000000 11947.5000 64.5811
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 5.000000 125.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 284 1455.000000 72750.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 35.000000 2500.4000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 7.000000 500.0800 71.4400
Subtotal (Total Children Is Unduplicated) 293 1502.000000 75875.4800 50.5163
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Total 1687.000000 87822.9800 52.0587
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Number of Children (Unduplicated) With at Least One Service 348
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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
1609 1687.000000 87822.9800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1609 1687.000000 87822.9800 0.0000