CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 4.500000 166.5000 37.0000
Subtotal (Total Children Is Unduplicated) 3 4.500000 166.5000 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 97.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 5.000000 242.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 11 11.000000 533.5000 48.5000
Subtotal (Total Children Is Unduplicated) 18 18.000000 873.0000 48.5000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 25.000000 1250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 50.500000 3427.9400 67.8800
PHY-97110-PT SESSION BY LICENSED PT 27 87.000000 5905.5600 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 186.000000 12625.6800 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.500000 27.1600 54.3200
Subtotal (Total Children Is Unduplicated) 75 349.000000 23236.3400 66.5798
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Total 371.500000 24275.8400 65.3455
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Number of Children (Unduplicated) With at Least One Service 87
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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 1 1.500000 101.8200 101.8200
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 7 33.500000 1826.9800 1826.9800
174 336.500000 22347.0400 22180.5400
Other 0 0.000000 0.0000 0.0000
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Total 182 371.500000 24275.8400 24109.3400