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
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 1 1.000000 51.0500 51.0500
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.500000 250.0400 71.4400
TRAV-TRAVS-Travel by mile 1 44.000000 19.5800 0.4450
Subtotal (Total Children Is Unduplicated) 2 47.500000 269.6200 5.6762
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Total 48.500000 320.6700 6.6118
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Number of Children (Unduplicated) With at Least One Service 2
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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 1 44.000000 19.5800 19.5800
6 4.500000 301.0900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7 48.500000 320.6700 19.5800