CMS/EIP Fiscal Report Center: 54
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: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-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 3 3.000000 177.1000 59.0333
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 39.000000 1950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 14.000000 1000.1600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 4 10.950000 786.1500 71.7945
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 17.000000 1214.4800 71.4400
TRAV-TRAVS-Travel by mile 19 782.000000 348.1100 0.4452
Subtotal (Total Children Is Unduplicated) 44 862.950000 5298.9000 6.1404
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Total 865.950000 5476.0000 6.3237
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Number of Children (Unduplicated) With at Least One Service 44
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Center 54
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 1 1.000000 50.0000 50.0000
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
136 864.950000 5426.0000 3175.3600
Other 0 0.000000 0.0000 0.0000
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Total 137 865.950000 5476.0000 3225.3600