CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 12.500000 937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 12.500000 693.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
Subtotal (Total Children Is Unduplicated) 17 33.000000 2231.2500 67.6136
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 36.750000 1837.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
PHY-97110-PT SESSION BY LICENSED PT 3 7.000000 500.0800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 27.000000 1928.8800 71.4400
TRAV-TRAVS-Travel by mile 1 33.000000 14.6900 0.4452
Subtotal (Total Children Is Unduplicated) 26 106.750000 4391.1500 41.1349
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Total 139.750000 6622.4000 47.3875
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Number of Children (Unduplicated) With at Least One Service 42
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Center 01
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 18 19.250000 1046.0700 1046.0700
D 65 68.500000 4195.1400 0.0000
S 9 14.500000 1087.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 3 36.000000 181.1900 181.1900
1 1.500000 112.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 96 139.750000 6622.4000 1227.2600