CMS/EIP Fiscal Report Center: 06
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
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 9 17.500000 875.0000 50.0000
Subtotal (Total Children Is Unduplicated) 9 17.500000 875.0000 50.0000
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 87.000000 4350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 9.000000 642.9600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 2.500000 178.6000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 23.000000 1643.1200 71.4400
Subtotal (Total Children Is Unduplicated) 15 122.500000 6864.6800 56.0382
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Total 140.000000 7739.6800 55.2834
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Number of Children (Unduplicated) With at Least One Service 24
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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
142 140.000000 7739.6800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 142 140.000000 7739.6800 0.0000