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: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 46 124.250000 4597.2500 37.0000
Subtotal (Total Children Is Unduplicated) 46 124.250000 4597.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 4 4.000000 194.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 7 7.000000 339.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 6 6.000000 291.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 17 17.000000 824.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 19 19.000000 921.5000 48.5000
Subtotal (Total Children Is Unduplicated) 48 53.000000 2570.5000 48.5000
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 642 5277.000000 263850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 73 446.250000 30291.4500 67.8800
PHY-97110-PT SESSION BY LICENSED PT 85 399.000000 27084.1200 67.8800
PHY-97110HM-PT SESSION BY PT ASST 4 7.500000 407.4000 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 60 312.750000 21229.4700 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 16.000000 869.1200 54.3200
Subtotal (Total Children Is Unduplicated) 729 6458.500000 343731.5600 53.2216
-----------------------------------------------------------------------------------------------------------------------
Total 6635.750000 350899.3100 52.8801
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 770
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 98 35.750000 1322.7500 1322.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1663 5642.500000 287967.4400 287642.2800
T 0 0.000000 0.0000 0.0000
394 892.000000 59060.2200 0.0000
Other 4 4.500000 291.9000 305.4600
---------------------------------------------------------
Total 2303 6635.750000 350899.3100 289270.4900