CMS/EIP Fiscal Report Center: 09
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:OTHER
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
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 4 35.000000 1750.0000 50.0000
Subtotal (Total Children Is Unduplicated) 4 35.000000 1750.0000 50.0000
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 19 25.000000 1250.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 5 4.500000 112.5000 25.0000
CONIF-CONIF-CONSULT, FACE TO FACE 68 81.250000 4062.5000 50.0000
CONIP-CONIP-CONSULT, PHONE 13 22.000000 550.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 109 413.000000 20650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 62.000000 4429.2800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 32 146.000000 10430.2400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 82 380.000000 27147.2000 71.4400
TRAV-TRAVS-Travel by mile 545 28296.00000 12392.0100 0.4379
Subtotal (Total Children Is Unduplicated) 579 29429.75000 81023.7300 2.7531
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Total 29464.750000 82773.7300 2.8092
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Number of Children (Unduplicated) With at Least One Service 582
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Center 09
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 1193 27010.500000 65763.4400 65763.4400
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 1 1.000000 50.0000 0.0000
161 2453.250000 16960.2900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1355 29464.750000 82773.7300 65763.4400