CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 5 19.000000 1357.3600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 171.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 7 51.000000 3643.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 2.500000 142.9000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 44.000000 3143.3600 71.4400
Subtotal (Total Children Is Unduplicated) 16 119.500000 8458.6600 70.7838
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Total 119.500000 8458.6600 70.7838
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Number of Children (Unduplicated) With at Least One Service 16
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Center 55
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
133 119.500000 8458.6600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 133 119.500000 8458.6600 0.0000