CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 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
CASE-CASE-NON-TCM CASE MANAGEMENT 68 43.500000 1609.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 99 142.000000 5254.0000 37.0000
Subtotal (Total Children Is Unduplicated) 102 185.500000 6863.5000 37.0000
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.000000 145.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 58 58.000000 2813.0000 48.5000
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 9 9.000000 436.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 31 31.000000 1503.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 34 38.000000 1843.0000 48.5000
Subtotal (Total Children Is Unduplicated) 120 139.000000 6741.5000 48.5000
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 63.750000 3187.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 10 10.000000 500.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 11.000000 550.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 103 3593.000000 89825.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1022 9433.250000 471462.5000 49.9788
OCCT-97530-OT SESSION BY LICENSED OT 167 1091.750000 74107.9900 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 36 226.500000 12303.4800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 131 560.250000 38029.7700 67.8800
PHY-97110HM-PT SESSION BY PT ASST 29 145.000000 7876.4000 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 132 642.000000 43578.9600 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 24.500000 1330.8400 54.3200
SPL-92508-GROUP SPL SESSION PER CHILD 17 14.500000 191.4000 13.2000
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 1037 10158.00000 101570.0000 9.9990
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 9 32.000000 16.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1234 26006.50000 844579.8400 32.4757
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Total 26331.000000 858184.8400 32.5922
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Number of Children (Unduplicated) With at Least One Service 1258
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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 95 71.000000 2627.0000 0.0000
P 4230 13197.000000 272968.6700 245066.9700
D 6 2.000000 74.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2464 8200.250000 414729.2000 297901.2000
T 0 0.000000 0.0000 0.0000
1011 4614.250000 152499.2300 0.0000
Other 99 246.500000 15286.7400 9822.1400
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Total 7905 26331.000000 858184.8400 552790.3100