CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2013 ending 03/31/2013 Date of Report:05/17/2013 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 43 64.750000 2395.7500 37.0000
Subtotal (Total Children Is Unduplicated) 43 64.750000 2395.7500 37.0000
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 12 13.000000 630.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 19 19.000000 921.5000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 7.000000 339.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 13 13.000000 630.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 23 23.000000 1115.5000 48.5000
Subtotal (Total Children Is Unduplicated) 60 75.000000 3637.5000 48.5000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 829 7182.000000 359100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 56 279.250000 18955.4900 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 162.9600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 46 184.500000 12523.8600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 4.000000 217.2800 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 34 156.000000 10589.2800 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.000000 162.9600 54.3200
Subtotal (Total Children Is Unduplicated) 879 7811.750000 401711.8300 51.4241
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Total 7951.500000 407745.0800 51.2790
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Number of Children (Unduplicated) With at Least One Service 916
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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 40 31.750000 1174.7500 0.0000
P 36 33.000000 1221.0000 1221.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2320 7477.500000 378441.5400 348018.1600
T 0 0.000000 0.0000 0.0000
222 409.250000 26907.7900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2618 7951.500000 407745.0800 349239.1600