CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 306.3000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 9 9.000000 459.4500 51.0500
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 10 38.500000 2750.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 12.500000 715.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 6 34.500000 2464.6800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 14.000000 1000.1600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.500000 85.8000 57.2000
Subtotal (Total Children Is Unduplicated) 21 101.000000 7016.0800 69.4661
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Total 110.000000 7475.5300 67.9594
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Number of Children (Unduplicated) With at Least One Service 24
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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 1 1.000000 71.4400 71.4400
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
1 1.000000 51.0500 0.0000
Other 46 108.000000 7353.0400 645.1400
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Total 48 110.000000 7475.5300 716.5800