CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 9 7.000000 259.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 108 159.750000 5910.7500 37.0000
Subtotal (Total Children Is Unduplicated) 109 166.750000 6169.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 306.3000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 8.000000 408.4000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 21 24.000000 1225.2000 51.0500
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 13 17.500000 875.0000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 3 3.000000 150.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 137.000000 3425.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1042 9148.000000 457400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1006 8817.000000 88170.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 111.500000 7461.6900 66.9210
OCCT-97530HM-OT SESSION BY OT ASST 6 27.250000 1534.8300 56.3240
PHY-97110-PT SESSION BY LICENSED PT 23 133.500000 9537.2400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 15 119.500000 6830.6200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 150.500000 10751.7200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 3.000000 171.6000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 1 6.000000 83.2800 13.8800
Subtotal (Total Children Is Unduplicated) 1107 18673.75000 586390.9800 31.4019
-----------------------------------------------------------------------------------------------------------------------
Total 18864.500000 593785.9300 31.4764
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1192
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 5 4.750000 175.7500 0.0000
P 3251 10911.750000 195540.9800 195340.9800
D 1 0.250000 9.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 2114 7523.500000 379053.4400 321.4800
T 0 0.000000 0.0000 0.0000
93 307.750000 11329.8900 0.0000
Other 45 116.500000 7676.6200 874.0100
---------------------------------------------------------
Total 5509 18864.500000 593785.9300 196536.4700