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
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 20 11.750000 434.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 42 59.000000 2183.0000 37.0000
Subtotal (Total Children Is Unduplicated) 59 70.750000 2617.7500 37.0000
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 6 6.000000 291.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.000000 679.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.000000 242.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.000000 339.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 14 14.000000 679.0000 48.5000
Subtotal (Total Children Is Unduplicated) 44 46.000000 2231.0000 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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 177 1461.500000 73075.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 72 446.000000 30274.4800 67.8800
PHY-97110-PT SESSION BY LICENSED PT 39 213.250000 14475.4100 67.8800
PHY-97110HM-PT SESSION BY PT ASST 4 21.000000 1140.7200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 39 253.000000 17173.6400 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 63.000000 3422.1600 54.3200
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 826 145040.0000 72520.0000 0.5000
Subtotal (Total Children Is Unduplicated) 877 147544.2500 214406.4100 1.4532
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Total 147661.000000 219255.1600 1.4849
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Number of Children (Unduplicated) With at Least One Service 918
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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 2987 147370.250000 214115.7700 212556.9100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 191.000000 661.6000 661.6000
T 0 0.000000 0.0000 0.0000
103 70.750000 2617.7500 0.0000
Other 11 29.000000 1860.0400 1554.5800
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Total 3107 147661.000000 219255.1600 214773.0900