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:MED
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 92 134.250000 4967.2500 37.0000
Subtotal (Total Children Is Unduplicated) 92 134.250000 4967.2500 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 5.000000 255.2500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 7 8.000000 408.4000 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 848 7353.000000 367650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 17.000000 1214.4800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 9 66.000000 4715.0400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 42.000000 2400.7200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 36.500000 2607.5600 71.4400
Subtotal (Total Children Is Unduplicated) 864 7515.500000 378645.0000 50.3819
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Total 7657.750000 384020.6500 50.1480
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Number of Children (Unduplicated) With at Least One Service 952
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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 5 4.750000 175.7500 0.0000
P 159 127.000000 4751.0000 4551.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2109 7514.000000 378460.4800 0.0000
T 0 0.000000 0.0000 0.0000
8 6.500000 240.5000 0.0000
Other 2 5.500000 392.9200 0.0000
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Total 2283 7657.750000 384020.6500 4551.0000