CMS/EIP Fiscal Report Center: 53
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: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-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 300.0000 66.6667
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 5 7.500000 462.0500 61.6067
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 465.4500 465.4500
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 17 80.550000 4027.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
TRAV-TRAVS-Travel by mile 1 6.000000 2.6800 0.4467
Subtotal (Total Children Is Unduplicated) 18 88.550000 4505.6300 50.8823
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Total 96.050000 4967.6800 51.7197
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Number of Children (Unduplicated) With at Least One Service 22
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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
72 96.050000 4967.6800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 72 96.050000 4967.6800 0.0000