CMS/EIP Fiscal Report Center: 57
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 1 0.750000 27.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.750000 27.7500 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 7 7.000000 350.0000 50.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 18 17.187000 833.5700 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.000000 533.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 24 23.690700 1149.0000 48.5000
Subtotal (Total Children Is Unduplicated) 49 58.877700 2866.0700 48.6784
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 18 18.000000 900.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 93 94.000000 4700.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 292 2545.000000 127250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 37.000000 2511.5600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 24 130.250000 8841.3700 67.8800
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 66 329.500000 22366.4600 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.500000 27.1600 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 26.4000 13.2000
TRAN-TRAN-FAMILY TRANSPORTATION 1 120.000000 60.0000 0.5000
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 747 150748.0000 78685.2000 0.5220
Subtotal (Total Children Is Unduplicated) 825 154026.2500 245468.1500 1.5937
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Total 154085.877700 248361.9700 1.6118
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Number of Children (Unduplicated) With at Least One Service 850
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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 110 5110.000000 6258.3200 6578.3200
H 0 0.000000 0.0000 0.0000
T 2938 148686.127700 241453.9000 242024.1400
10 289.750000 649.7500 622.0000
Other 0 0.000000 0.0000 0.0000
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Total 3058 154085.877700 248361.9700 249224.4600