CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.750000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1 0.750000 0.0000 0.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 55 96.000000 19200.0000 200.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 400.0000 200.0000
Subtotal (Total Children Is Unduplicated) 57 98.000000 19600.0000 200.0000
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 3 13.500000 2700.0000 200.0000
PHY-97110-PT SESSION BY LICENSED PT 16 60.250000 12250.0000 203.3195
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 82.500000 16475.0000 199.6970
Subtotal (Total Children Is Unduplicated) 28 156.250000 31425.0000 201.1200
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Total 255.000000 51025.0000 200.0980
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Number of Children (Unduplicated) With at Least One Service 84
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Center 03
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 251 248.250000 49625.0000 0.0000
T 0 0.000000 0.0000 0.0000
7 6.750000 1400.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 258 255.000000 51025.0000 0.0000