CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
Subtotal (Total Children Is Unduplicated) 2 4.000000 300.0000 75.0000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 214.3200 71.4400
Subtotal (Total Children Is Unduplicated) 2 7.000000 414.3200 59.1886
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Total 11.000000 714.3200 64.9382
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Number of Children (Unduplicated) With at Least One Service 4
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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 0 0.000000 0.0000 0.0000
7 7.000000 414.3200 0.0000
Other 2 4.000000 300.0000 0.0000
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Total 9 11.000000 714.3200 0.0000