CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 2 2.000000 102.1000 51.0500
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 4 11.000000 785.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 16.000000 1143.0400 71.4400
Subtotal (Total Children Is Unduplicated) 17 35.000000 2400.6400 68.5897
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Total 37.000000 2502.7400 67.6416
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Number of Children (Unduplicated) With at Least One Service 18
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Center 03
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
37 37.000000 2502.7400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 37 37.000000 2502.7400 0.0000