CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 5 11.250000 416.2500 37.0000
Subtotal (Total Children Is Unduplicated) 5 11.250000 416.2500 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
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) 3 3.000000 153.1500 51.0500
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EI Services,Class #03
CONIF-CONIF-CONSULT, FACE TO FACE 15 15.000000 750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 28 47.000000 470.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 23.000000 1643.1200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 171.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 1.000000 71.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 4.000000 228.6400 57.1600
Subtotal (Total Children Is Unduplicated) 31 95.000000 3434.8000 36.1558
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Total 109.250000 4004.2000 36.6517
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Number of Children (Unduplicated) With at Least One Service 36
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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 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 1 -3.000000 -30.0000 -30.0000
10 11.250000 416.2500 0.0000
Other 69 101.000000 3617.9500 3679.3900
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Total 80 109.250000 4004.2000 3649.3900