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
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 7.000000 482.2200 68.8886
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 9.000000 642.9600 71.4400
Subtotal (Total Children Is Unduplicated) 6 18.000000 1246.6200 69.2567
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Total 18.000000 1246.6200 69.2567
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Number of Children (Unduplicated) With at Least One Service 6
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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 6 6.000000 410.7800 285.7600
12 12.000000 835.8400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 18 18.000000 1246.6200 285.7600