CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 134 184.500000 6826.5000 37.0000
Subtotal (Total Children Is Unduplicated) 134 184.500000 6826.5000 37.0000
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Screening, Eval, and Assessment,Class #02
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 15 15.000000 765.7500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 37 37.000000 1888.8500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 17 17.000000 867.8500 51.0500
Subtotal (Total Children Is Unduplicated) 73 78.000000 3981.9000 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 949 9679.000000 483950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 46 346.750000 24771.8200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 10 66.500000 3803.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 39 222.750000 15913.2600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 38 303.000000 17319.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 162.000000 11573.2800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.000000 228.8000 57.2000
Subtotal (Total Children Is Unduplicated) 1019 10784.00000 557560.4400 51.7026
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Total 11046.500000 568368.8400 51.4524
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Number of Children (Unduplicated) With at Least One Service 1128
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 87 75.000000 2775.0000 0.0000
P 84 60.750000 2247.7500 2247.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2546 10404.500000 529409.0700 0.0000
T 0 0.000000 0.0000 0.0000
227 506.000000 33927.7700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2945 11046.500000 568368.8400 2247.7500