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:TPIN
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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 15.500000 1162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 18.000000 1350.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 14 35.500000 2614.6000 73.6507
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 23.000000 1150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 26.000000 1857.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 23 126.000000 9001.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 73.000000 5215.1200 71.4400
Subtotal (Total Children Is Unduplicated) 43 248.000000 17224.0000 69.4516
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Total 283.500000 19838.6000 69.9774
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Number of Children (Unduplicated) With at Least One Service 55
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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 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
107 283.500000 19838.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 107 283.500000 19838.6000 0.0000