CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/16/2012 Page: 1
List order: No List
Agency Filter:EXT
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 20 11.750000 434.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 78 183.250000 6780.2500 37.0000
Subtotal (Total Children Is Unduplicated) 78 195.000000 7215.0000 37.0000
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 10 10.000000 485.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 22 22.000000 1067.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 12 12.000000 582.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 26 26.000000 1261.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 36 36.000000 1746.0000 48.5000
Subtotal (Total Children Is Unduplicated) 98 106.000000 5141.0000 48.5000
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 19 32.500000 1625.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 5 5.000000 250.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 40 3872.000000 96800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 98 2736.000000 68400.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 822 6982.500000 349125.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 199 1112.750000 75533.4700 67.8800
PHY-97110-PT SESSION BY LICENSED PT 176 838.000000 56883.4400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 8 28.500000 1548.1200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 152 754.250000 51198.4900 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 15 79.000000 4291.2800 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 15 17.500000 231.0000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 826 145040.0000 72520.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1034 161507.0000 778855.8000 4.8224
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Total 161808.000000 791211.8000 4.8898
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Number of Children (Unduplicated) With at Least One Service 1036
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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 144 61.000000 2257.0000 0.0000
P 3107 147483.000000 219288.5200 217529.6600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1670 5836.500000 288832.6800 288507.5200
T 0 0.000000 0.0000 0.0000
1271 8312.000000 273212.4000 0.0000
Other 54 115.500000 7621.2000 7280.8000
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Total 6246 161808.000000 791211.8000 513317.9800