CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 7 5.500000 203.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 115 155.000000 5735.0000 37.0000
Subtotal (Total Children Is Unduplicated) 115 160.500000 5938.5000 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 20 20.000000 1000.1800 50.0090
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.000000 255.2500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 20 20.000000 1021.0000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 15 15.000000 765.7500 51.0500
Subtotal (Total Children Is Unduplicated) 53 61.000000 3093.2300 50.7087
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 36 70.500000 3525.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 2.000000 100.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 68 5223.000000 130575.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1051 9033.000000 451650.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1025 8864.000000 88640.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 61 332.000000 23268.0800 70.0846
OCCT-97530HM-OT SESSION BY OT ASST 10 62.000000 3496.4000 56.3935
PHY-97110-PT SESSION BY LICENSED PT 58 223.500000 15966.8400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 25 244.500000 13964.0800 57.1128
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 229.750000 16413.3400 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 23.000000 1315.6000 57.2000
Subtotal (Total Children Is Unduplicated) 1208 24310.25000 749064.3400 30.8127
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Total 24531.750000 758096.0700 30.9026
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Number of Children (Unduplicated) With at Least One Service 1237
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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 1 1.250000 46.2500 0.0000
P 3158 10826.750000 191107.2400 191107.0800
D 2 6.250000 96.2500 40.0000
S 1 5.000000 250.0000 0.0000
H 2109 7805.500000 391918.6700 947.2000
T 0 0.000000 0.0000 0.0000
502 5778.500000 167278.9000 0.0000
Other 47 108.500000 7398.7600 2200.4400
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Total 5820 24531.750000 758096.0700 194294.7200