CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 88 151.750000 5614.7500 37.0000
Subtotal (Total Children Is Unduplicated) 88 151.750000 5614.7500 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-97166-OT EVAL MODERATE COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 21 21.000000 1072.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 13 13.000000 663.6500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 48 48.000000 2450.4000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 5 5.000000 255.2500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 12 12.000000 587.2800 48.9400
Subtotal (Total Children Is Unduplicated) 108 112.000000 5692.2800 50.8239
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1028 10739.00000 536950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 40 157.500000 11251.8000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 70 326.500000 18675.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 43 260.250000 18592.2600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 87 447.750000 25593.3900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 52.500000 3750.6000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.000000 228.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 18 20.250000 281.0700 13.8800
Subtotal (Total Children Is Unduplicated) 1110 12007.75000 615323.7200 51.2439
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Total 12271.500000 626630.7500 51.0639
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Number of Children (Unduplicated) With at Least One Service 1172
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Center 04
Flag Claims Units Chgs Paid
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R 1 1.000000 37.0000 37.0000
U 0 0.000000 0.0000 0.0000
B 34 37.500000 1387.5000 0.0000
P 153 163.750000 7596.3400 4304.9900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3005 11870.500000 606255.7700 0.0000
T 0 0.000000 0.0000 0.0000
150 198.750000 11354.1400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3343 12271.500000 626630.7500 4341.9900