CMS/EIP Fiscal Report Center: 09
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 1 0.750000 27.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.750000 27.7500 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 3 3.000000 153.1500 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 606 4131.000000 206550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 175.000000 12502.0000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 62 438.000000 31290.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 67 489.000000 34934.1600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 703 5237.000000 285462.2400 54.5087
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Total 5240.750000 285643.1400 54.5042
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Number of Children (Unduplicated) With at Least One Service 704
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Center 09
Flag Claims Units Chgs Paid
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R 2 1.750000 77.7500 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
1742 5239.000000 285565.3900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1744 5240.750000 285643.1400 0.0000