CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:OTHER
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 1 0.500000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1 0.500000 0.0000 0.0000
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 1.750000 87.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 5.250000 262.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 7 10.000000 542.8800 54.2880
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Total 10.500000 542.8800 51.7029
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Number of Children (Unduplicated) With at Least One Service 7
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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 0 0.000000 0.0000 0.0000
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 0 0.000000 0.0000 0.0000
11 10.500000 542.8800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11 10.500000 542.8800 0.0000