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: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 99 133.000000 4921.0000 37.0000
Subtotal (Total Children Is Unduplicated) 99 133.000000 4921.0000 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 13 13.000000 663.6500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.000000 255.2500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 16 16.000000 816.8000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 510.5000 51.0500
Subtotal (Total Children Is Unduplicated) 38 45.000000 2297.2500 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 871 7451.000000 372550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 38 240.500000 17181.3200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 12.000000 686.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 24 127.250000 9090.7400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 14 124.000000 7087.8400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 104.000000 7429.7600 71.4400
Subtotal (Total Children Is Unduplicated) 921 8058.750000 414026.0600 51.3760
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Total 8236.750000 421244.3100 51.1421
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Number of Children (Unduplicated) With at Least One Service 1002
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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 159 131.750000 4874.7500 4874.7500
D 0 0.000000 0.0000 0.0000
S 1 5.000000 250.0000 0.0000
H 2091 7744.500000 391214.2700 357.2000
T 0 0.000000 0.0000 0.0000
144 354.250000 24859.0400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2396 8236.750000 421244.3100 5231.9500