CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 242.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 48.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 8 8.000000 388.0000 48.5000
Subtotal (Total Children Is Unduplicated) 9 17.000000 824.5000 48.5000
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 103 3588.000000 89700.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 149.000000 7450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 18 77.750000 5277.6700 67.8800
PHY-97110-PT SESSION BY LICENSED PT 44 103.000000 6991.6400 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 137.000000 9299.5600 67.8800
SPL-92508-GROUP SPL SESSION PER CHILD 17 14.500000 191.4000 13.2000
Subtotal (Total Children Is Unduplicated) 117 4069.250000 118910.2700 29.2217
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Total 4086.250000 119734.7700 29.3019
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Number of Children (Unduplicated) With at Least One Service 117
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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
577 4086.250000 119734.7700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 577 4086.250000 119734.7700 0.0000