CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:LEA
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
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 1 2.000000 102.1000 51.0500
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 137.000000 3425.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 120.000000 6000.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 2 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 3.000000 214.3200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 6.000000 83.2800 13.8800
Subtotal (Total Children Is Unduplicated) 20 267.000000 9794.0400 36.6818
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Total 269.000000 9896.1400 36.7886
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Number of Children (Unduplicated) With at Least One Service 20
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Center 04
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
35 269.000000 9896.1400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 35 269.000000 9896.1400 0.0000