CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:TPIN
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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 2 2.000000 102.1000 51.0500
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 3 9.500000 678.6800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 7.000000 400.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 7 40.000000 2857.6000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 21.000000 1200.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 21.000000 1500.2400 71.4400
Subtotal (Total Children Is Unduplicated) 18 98.500000 6637.2800 67.3836
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Total 100.500000 6739.3800 67.0585
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Number of Children (Unduplicated) With at Least One Service 18
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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 1 3.000000 171.4800 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 36 97.500000 6567.9000 551.1300
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Total 37 100.500000 6739.3800 551.1300