CMS/EIP Fiscal Report Center: 10
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:MED
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 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 4 4.000000 204.2000 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 805 7354.250000 367687.5000 49.9966
OCCT-97530-OT SESSION BY LICENSED OT 39 205.500000 14680.9200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 0.500000 28.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 48 218.750000 15627.5000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 45 270.750000 19342.3800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 3 7.750000 107.5700 13.8800
Subtotal (Total Children Is Unduplicated) 867 8057.500000 417474.4700 51.8119
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Total 8061.500000 417678.6700 51.8115
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Number of Children (Unduplicated) With at Least One Service 867
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Center 10
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
2516 8061.500000 417678.6700 10.0000
Other 0 0.000000 0.0000 0.0000
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Total 2516 8061.500000 417678.6700 10.0000