CMS/EIP Fiscal Report Center: 53
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: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-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 47.500000 2636.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 51.000000 3825.0000 75.0000
Subtotal (Total Children Is Unduplicated) 55 104.000000 6766.5000 65.0625
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 287 1847.250000 92362.5000 50.0000
Subtotal (Total Children Is Unduplicated) 287 1848.250000 92387.5000 49.9865
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Total 1952.250000 99154.0000 50.7896
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Number of Children (Unduplicated) With at Least One Service 319
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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
1910 1952.250000 99154.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1910 1952.250000 99154.0000 0.0000