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:TPIN
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 1 1.750000 64.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1 1.750000 64.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 409.4500 45.4944
PSTH-97163-PT EVAL HIGH COMPLEXITY 13 13.000000 643.6500 49.5115
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 9 9.000000 414.4500 46.0500
Subtotal (Total Children Is Unduplicated) 30 33.000000 1569.6500 47.5652
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 29 123.000000 8175.2400 66.4654
OCCT-97530HM-OT SESSION BY OT ASST 8 36.500000 2087.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 13 68.500000 4217.5000 61.5693
PHY-97110HM-PT SESSION BY PT ASST 6 36.500000 2086.3400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 141.000000 9704.1500 68.8238
Subtotal (Total Children Is Unduplicated) 64 405.500000 26271.0300 64.7868
-----------------------------------------------------------------------------------------------------------------------
Total 440.250000 27905.4300 63.3854
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 69
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 115 236.000000 14126.3700 10763.4800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 1.750000 64.7500 0.0000
Other 75 202.500000 13714.3100 0.0000
---------------------------------------------------------
Total 191 440.250000 27905.4300 10763.4800