CMS/EIP Fiscal Report Center: 09
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
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 1 1.000000 51.0500 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 26.000000 1857.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 9 98.000000 6930.6800 70.7212
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 43.000000 3071.9200 71.4400
Subtotal (Total Children Is Unduplicated) 19 168.000000 11910.0400 70.8931
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Total 169.000000 11961.0900 70.7757
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Number of Children (Unduplicated) With at Least One Service 19
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Center 09
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
44 169.000000 11961.0900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 44 169.000000 11961.0900 0.0000