CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 36.000000 2059.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 18.000000 1285.9200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 12.000000 685.9200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 28.000000 2000.3200 71.4400
Subtotal (Total Children Is Unduplicated) 6 96.000000 6174.2400 64.3150
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Total 96.000000 6174.2400 64.3150
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Number of Children (Unduplicated) With at Least One Service 6
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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
96 96.000000 6174.2400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 96 96.000000 6174.2400 0.0000