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
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 7 13.000000 481.0000 37.0000
Subtotal (Total Children Is Unduplicated) 7 13.000000 481.0000 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 6 6.000000 291.0000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 44 44.000000 2134.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.000000 194.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 8 8.000000 388.0000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 23 23.000000 1115.5000 48.5000
Subtotal (Total Children Is Unduplicated) 80 86.000000 4171.0000 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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 195 1640.750000 82037.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 106 730.000000 49552.4000 67.8800
PHY-97110-PT SESSION BY LICENSED PT 39 243.000000 16494.8400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 2 4.000000 217.2800 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 205.500000 13949.3400 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 34.000000 1846.8800 54.3200
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 961 184520.0000 92260.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1019 187443.0000 259645.7400 1.3852
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Total 187542.000000 264297.7400 1.4093
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Number of Children (Unduplicated) With at Least One Service 1026
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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 3889 187325.000000 262206.4000 259237.3200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 186.000000 407.8800 407.8800
T 0 0.000000 0.0000 0.0000
15 13.000000 481.0000 0.0000
Other 9 18.000000 1202.4600 339.4000
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Total 3919 187542.000000 264297.7400 259984.6000