CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Payclass Filters:LEA
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 68 5223.000000 130575.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 75.000000 3750.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 14.500000 1035.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 22 37.750000 2696.8600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 46.750000 3339.8200 71.4400
Subtotal (Total Children Is Unduplicated) 73 5397.000000 141397.5600 26.1993
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Total 5397.000000 141397.5600 26.1993
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Number of Children (Unduplicated) With at Least One Service 73
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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 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
315 5397.000000 141397.5600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 315 5397.000000 141397.5600 0.0000