CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
Subtotal (Total Children Is Unduplicated) 2 4.000000 222.0000 55.5000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 13.000000 650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 17.000000 1214.4800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 24.000000 1607.4000 66.9750
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 28.000000 2000.3200 71.4400
Subtotal (Total Children Is Unduplicated) 17 82.000000 5472.2000 66.7341
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Total 86.000000 5694.2000 66.2116
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Number of Children (Unduplicated) With at Least One Service 19
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Center 02
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 18 18.000000 1228.7600 541.4700
65 66.000000 4354.4400 0.0000
Other 1 2.000000 111.0000 0.0000
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Total 84 86.000000 5694.2000 541.4700