CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 3.000000 51.5500 17.1833
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 54 89.000000 6675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 136 214.000000 11877.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 39.000000 2925.0000 75.0000
Subtotal (Total Children Is Unduplicated) 187 353.500000 22068.5500 62.4287
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 170 349.000000 17450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 18 33.000000 2357.5200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 10.000000 696.5400 69.6540
Subtotal (Total Children Is Unduplicated) 192 394.000000 20646.9400 52.4034
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Total 747.500000 42715.4900 57.1445
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Number of Children (Unduplicated) With at Least One Service 376
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Center 01
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 130 130.000000 6650.0800 3950.0800
D 107 111.000000 5589.8300 0.0000
S 9 12.500000 787.1300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 372 494.000000 29688.4500 0.0000
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Total 618 747.500000 42715.4900 3950.0800