CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:OTHER
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
EXIT-EXIT-EXIT ASSESSMENT 11 20.000000 1000.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
Subtotal (Total Children Is Unduplicated) 13 28.000000 1522.0000 54.3571
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.000000 400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 22.000000 1571.6800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 10.000000 714.4000 71.4400
Subtotal (Total Children Is Unduplicated) 3 40.000000 2686.0800 67.1520
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Total 68.000000 4208.0800 61.8835
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Number of Children (Unduplicated) With at Least One Service 16
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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
58 68.000000 4208.0800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 58 68.000000 4208.0800 0.0000