CMS/EIP Fiscal Report Center: 57
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 3.750000 138.7500 37.0000
Subtotal (Total Children Is Unduplicated) 3 3.750000 138.7500 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 12 12.000000 600.0000 50.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 7 7.000000 339.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 242.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 6.000000 291.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 20 19.381400 940.0000 48.5001
Subtotal (Total Children Is Unduplicated) 46 52.381400 2558.5000 48.8437
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 35 35.000000 1750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 289 2559.250000 127962.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 96.500000 6550.4200 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 3 13.500000 733.3200 54.3200
PHY-97110-PT SESSION BY LICENSED PT 32 117.250000 7958.9300 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 108.6400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 107 536.671300 36429.2500 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 21 65.131800 3537.9600 54.3200
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 793 156317.0000 81413.9000 0.5208
Subtotal (Total Children Is Unduplicated) 868 159745.3031 266594.9200 1.6689
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Total 159801.434500 269292.1700 1.6852
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Number of Children (Unduplicated) With at Least One Service 889
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Center 57
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 45 1289.500000 2778.1400 2778.1400
H 0 0.000000 0.0000 0.0000
T 3242 158508.184500 266375.2800 266375.2800
5 3.750000 138.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3292 159801.434500 269292.1700 269153.4200