CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 5 2.000000 74.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 13 19.500000 721.5000 37.0000
Subtotal (Total Children Is Unduplicated) 17 21.500000 795.5000 37.0000
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Screening, Eval, and Assessment,Class #02
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 18 18.000000 918.9000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 23 25.000000 1276.2500 51.0500
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 45 110.250000 5512.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 222 2076.000000 103800.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1203 12538.00000 125380.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 155.000000 11073.2000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 18 98.000000 5605.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 9 47.000000 3179.0800 67.6400
PHY-97110HM-PT SESSION BY PT ASST 9 41.000000 2343.5600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 90.500000 6465.3200 71.4400
Subtotal (Total Children Is Unduplicated) 1260 15157.75000 263459.2600 17.3812
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Total 15204.250000 265531.0100 17.4643
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Number of Children (Unduplicated) With at Least One Service 1270
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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 3792 15055.750000 259544.6600 259544.6600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 30 117.500000 4843.6900 834.6400
T 0 0.000000 0.0000 0.0000
28 21.500000 795.5000 0.0000
Other 3 9.500000 347.1600 347.1600
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Total 3853 15204.250000 265531.0100 260726.4600