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: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
CASE-CASE-NON-TCM CASE MANAGEMENT 8 2.500000 92.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 34 69.500000 2571.5000 37.0000
Subtotal (Total Children Is Unduplicated) 35 73.000000 2664.0000 36.4932
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
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 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 62.000000 4497.5600 72.5413
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 44.000000 3062.1200 69.5936
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 100.000000 5233.9700 52.3397
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 9 9.000000 450.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 70 238.000000 14769.8500 62.0582
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 0.500000 25.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 51 268.750000 13437.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 44.750000 3196.9400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 13.500000 964.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 28.500000 1629.0600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 199.750000 14246.5600 71.3220
TRAV-TRAVS-Travel by mile 2 78.000000 34.7200 0.4451
Subtotal (Total Children Is Unduplicated) 99 639.750000 33634.2200 52.5740
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Total 950.750000 51068.0700 53.7135
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Number of Children (Unduplicated) With at Least One Service 163
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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 102 111.750000 6347.4900 4963.8000
D 138 143.500000 8443.1200 40.0000
S 1 3.000000 214.3200 0.0000
H 96 101.750000 6755.4200 0.0000
T 21 100.750000 1293.4400 860.4300
430 490.000000 28014.2800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 788 950.750000 51068.0700 5864.2300