CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 3 3.000000 153.1500 51.0500
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 12 11.500000 575.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 22.000000 1100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 48 150.000000 1500.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.500000 107.1600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 7 15.500000 885.9800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 5.500000 392.9200 71.4400
Subtotal (Total Children Is Unduplicated) 53 208.000000 4661.0600 22.4089
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Total 211.000000 4814.2100 22.8162
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Number of Children (Unduplicated) With at Least One Service 54
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Center 57
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
0 0.000000 0.0000 0.0000
Other 101 211.000000 4814.2100 4854.2100
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Total 101 211.000000 4814.2100 4854.2100