CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 12 23.500000 1762.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 25.500000 1415.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 13 51.000000 3327.7500 65.2500
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 1 1.000000 71.4400 71.4400
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Total 52.000000 3399.1900 65.3690
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Number of Children (Unduplicated) With at Least One Service 14
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Center 06
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
27 52.000000 3399.1900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 27 52.000000 3399.1900 0.0000