CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 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
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.000000 339.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 4 4.000000 194.0000 48.5000
Subtotal (Total Children Is Unduplicated) 8 12.000000 582.0000 48.5000
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EI Services,Class #03
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 3 272.000000 6800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 73 2202.000000 55050.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 198.000000 9900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 61.250000 4157.6500 67.8800
PHY-97110-PT SESSION BY LICENSED PT 41 141.000000 9571.0800 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 104.250000 7076.4900 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 2 1.000000 13.2000 13.2000
Subtotal (Total Children Is Unduplicated) 86 2979.500000 92568.4200 31.0684
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Total 2991.500000 93150.4200 31.1384
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Number of Children (Unduplicated) With at Least One Service 86
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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
451 2991.500000 93150.4200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 451 2991.500000 93150.4200 0.0000