CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2012 ending 12/31/2012 Date of Report:02/16/2013 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 58 73.500000 2719.5000 37.0000
Subtotal (Total Children Is Unduplicated) 58 73.500000 2719.5000 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 15 15.000000 727.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 61 61.000000 2958.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 12 12.000000 582.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 22 22.000000 1067.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 39 39.000000 1891.5000 48.5000
Subtotal (Total Children Is Unduplicated) 135 150.000000 7275.0000 48.5000
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 26 45.750000 2287.5000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 4 4.000000 200.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 9.000000 450.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 5 5.000000 250.0000 50.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 4 632.000000 15800.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 82 2846.000000 71150.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 949 8803.750000 440137.5000 49.9943
OCCT-97530-OT SESSION BY LICENSED OT 163 1072.000000 72767.3600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 132 662.250000 44953.5300 67.8800
PHY-97110HM-PT SESSION BY PT ASST 3 4.500000 244.4400 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 108 575.500000 38955.5800 67.6900
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 34.000000 1846.8800 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.2000 13.2000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 961 184520.0000 92260.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1120 199221.7500 781665.9900 3.9236
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Total 199445.250000 791660.4900 3.9693
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Number of Children (Unduplicated) With at Least One Service 1124
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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 36 35.250000 1304.2500 0.0000
P 3969 187480.250000 269944.6100 263254.5100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2141 7325.000000 361215.2800 360811.3000
T 0 0.000000 0.0000 0.0000
769 4522.250000 153807.2100 0.0000
Other 45 82.500000 5389.1400 2290.8600
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Total 6960 199445.250000 791660.4900 626356.6700