CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 1
List order: No List
Payclass Filters:LEA
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
PSTH-97163-PT EVAL HIGH COMPLEXITY 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
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 69 5673.000000 141825.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 85.000000 4250.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 16 27.000000 1928.8800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 33 83.000000 4744.2800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 72.750000 5197.2600 71.4400
Subtotal (Total Children Is Unduplicated) 78 5940.750000 157945.4200 26.5868
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Total 5941.750000 157996.4700 26.5909
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Number of Children (Unduplicated) With at Least One Service 78
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Center 04
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
376 5941.750000 157996.4700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 376 5941.750000 157996.4700 0.0000