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: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 2 2.000000 88.6500 44.3250
PSTH-97001-EVAL BY LICENSED PT, 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) 4 4.000000 190.7500 47.6875
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 90.000000 4500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 92.000000 6452.6400 70.1374
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 37 156.500000 10710.0900 68.4351
PHY-97110HM-PT SESSION BY PT ASST 1 2.500000 142.9000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 103.250000 7349.3000 71.1797
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 74 449.250000 29267.6500 65.1478
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Total 453.250000 29458.4000 64.9937
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Number of Children (Unduplicated) With at Least One Service 76
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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
209 453.250000 29458.4000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 209 453.250000 29458.4000 0.0000