CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 16 18.000000 918.9000 51.0500
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 16 78.000000 5536.6000 70.9821
OCCT-97530HM-OT SESSION BY OT ASST 4 30.500000 1744.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 7 34.000000 2357.5200 69.3388
PHY-97110HM-PT SESSION BY PT ASST 8 52.000000 2972.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 79.000000 5643.7600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 12.500000 715.0000 57.2000
Subtotal (Total Children Is Unduplicated) 45 286.000000 18969.8000 66.3280
-----------------------------------------------------------------------------------------------------------------------
Total 304.000000 19888.7000 65.4234
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 48
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 38 101.500000 6455.4700 6455.4700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 5.000000 357.2000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 81 197.500000 13076.0300 336.8100
---------------------------------------------------------
Total 120 304.000000 19888.7000 6792.2800