CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 8 14.250000 712.5000 50.0000
Subtotal (Total Children Is Unduplicated) 8 14.250000 712.5000 50.0000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 83.000000 4150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.500000 178.6000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 7.500000 535.8000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 0.500000 28.5800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 11.500000 821.5600 71.4400
Subtotal (Total Children Is Unduplicated) 14 105.000000 5714.5400 54.4242
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Total 119.250000 6427.0400 53.8955
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Number of Children (Unduplicated) With at Least One Service 22
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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
117 119.250000 6427.0400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 117 119.250000 6427.0400 0.0000