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
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 7 5.500000 203.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 16 22.000000 814.0000 37.0000
Subtotal (Total Children Is Unduplicated) 22 27.500000 1017.5000 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 234.4300 46.8860
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 10 11.000000 540.7300 49.1573
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 183 1507.000000 75350.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1025 8864.000000 88640.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 60.000000 3836.4000 63.9400
OCCT-97530HM-OT SESSION BY OT ASST 6 45.000000 2524.0000 56.0889
PHY-97110-PT SESSION BY LICENSED PT 10 53.500000 3822.0400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 12 120.500000 6876.2400 57.0642
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 45.500000 3250.5200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 23.000000 1315.6000 57.2000
Subtotal (Total Children Is Unduplicated) 1083 10794.00000 189389.8000 17.5458
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Total 10832.500000 190948.0300 17.6273
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Number of Children (Unduplicated) With at Least One Service 1094
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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 2999 10695.000000 186232.4900 186232.3300
D 2 6.250000 96.2500 40.0000
S 0 0.000000 0.0000 0.0000
H 17 59.000000 590.0000 590.0000
T 0 0.000000 0.0000 0.0000
42 26.250000 971.2500 0.0000
Other 18 46.000000 3058.0400 1521.7600
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Total 3078 10832.500000 190948.0300 188384.0900