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
Payclass Filters:GR
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 17 25.500000 943.5000 37.0000
Subtotal (Total Children Is Unduplicated) 24 32.500000 1202.5000 37.0000
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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 4 4.000000 204.2000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.000000 153.1500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 11 12.000000 612.6000 51.0500
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 200 1675.000000 83750.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1006 8817.000000 88170.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 85.000000 5568.5300 65.5121
OCCT-97530HM-OT SESSION BY OT ASST 4 19.250000 1077.2300 55.9600
PHY-97110-PT SESSION BY LICENSED PT 5 26.500000 1893.1600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 8 56.500000 3229.5400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 90.000000 6429.6000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 3.000000 171.6000 57.2000
Subtotal (Total Children Is Unduplicated) 1044 10792.75000 191314.6600 17.7262
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Total 10837.250000 193129.7600 17.8209
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Number of Children (Unduplicated) With at Least One Service 1065
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Center 04
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 3092 10784.750000 190789.9800 190789.9800
D 1 0.250000 9.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 4 6.500000 421.4800 321.4800
T 0 0.000000 0.0000 0.0000
50 32.250000 1193.2500 0.0000
Other 7 13.500000 715.8000 322.8800
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Total 3154 10837.250000 193129.7600 191434.3400