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
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
CASE-CASE-NON-TCM CASE MANAGEMENT 68 43.500000 1609.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 28 39.000000 1443.0000 37.0000
Subtotal (Total Children Is Unduplicated) 83 82.500000 3052.5000 37.0000
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Screening, Eval, and Assessment,Class #02
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 36 36.000000 1746.0000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.000000 339.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 16 20.000000 970.0000 48.5000
Subtotal (Total Children Is Unduplicated) 59 64.000000 3104.0000 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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 195 1643.000000 82150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 87 597.000000 40524.3600 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 24 144.000000 7822.0800 54.3200
PHY-97110-PT SESSION BY LICENSED PT 29 175.500000 11912.9400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 14 53.000000 2878.9600 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 258.000000 17513.0400 67.8800
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 24.500000 1330.8400 54.3200
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 1037 10157.00000 101560.0000 9.9990
TRAV-TRAV-PROV TRAVEL TO NATURAL ENV PER MINUTE 9 32.000000 16.0000 0.5000
Subtotal (Total Children Is Unduplicated) 1101 13169.75000 269995.7200 20.5012
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Total 13316.250000 276152.2200 20.7380
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Number of Children (Unduplicated) With at Least One Service 1165
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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 4170 13134.250000 270118.7600 243012.0500
D 6 2.000000 74.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 19 52.000000 697.8800 681.4800
T 0 0.000000 0.0000 0.0000
208 80.500000 2978.5000 0.0000
Other 15 47.500000 2283.0800 2034.8300
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Total 4418 13316.250000 276152.2200 245728.3600