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: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 121 172.750000 6391.7500 37.0000
Subtotal (Total Children Is Unduplicated) 121 172.750000 6391.7500 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97167-OT EVAL HIGH COMPLEXITY 20 20.000000 1021.0000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 32 32.000000 1633.6000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 61 61.000000 3114.0500 51.0500
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 965 9946.000000 497300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 49 256.500000 18324.3600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 31 199.500000 11411.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 31 231.000000 16502.6400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 55 334.000000 19091.4400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 137.750000 9840.8600 71.4400
Subtotal (Total Children Is Unduplicated) 1030 11108.75000 572570.7000 51.5423
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Total 11342.500000 582076.5000 51.3182
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Number of Children (Unduplicated) With at Least One Service 1140
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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 44 44.750000 1655.7500 0.0000
P 162 168.000000 7544.7300 4736.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2542 10804.500000 549833.7000 0.0000
T 0 0.000000 0.0000 0.0000
109 325.250000 23042.3200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2857 11342.500000 582076.5000 4736.0000