CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 3 3.500000 214.6000 61.3143
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 0.750000 53.5800 71.4400
Subtotal (Total Children Is Unduplicated) 1 0.750000 53.5800 71.4400
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Total 4.250000 268.1800 63.1012
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Number of Children (Unduplicated) With at Least One Service 3
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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
3 2.750000 155.6800 0.0000
Other 1 1.500000 112.5000 0.0000
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Total 4 4.250000 268.1800 0.0000