CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 0.750000 25.0000 33.3333
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 5.500000 203.5000 37.0000
Subtotal (Total Children Is Unduplicated) 6 6.250000 228.5000 36.5600
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 45.500000 2998.2600 65.8958
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 24.000000 1700.0000 70.8333
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 88.500000 4807.2300 54.3190
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 4.000000 204.2000 51.0500
SCREEN-T1023-SCREENING 8 8.000000 400.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 59 186.000000 11227.2400 60.3615
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.250000 112.5000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 2 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 57 214.000000 10617.5000 49.6145
OCCT-97530-OT SESSION BY LICENSED OT 9 47.000000 3357.6800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 24.000000 1714.5600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 123.250000 8804.9800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 93 421.500000 25041.3800 59.4102
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Total 613.750000 36497.1200 59.4658
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Number of Children (Unduplicated) With at Least One Service 137
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Center 52
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 19 28.000000 838.7400 838.7400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 158 167.250000 10848.7500 7162.5000
358 418.500000 24809.6300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 535 613.750000 36497.1200 8001.2400