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
Payclass Filters:OTHER
Eligibility Filter:Program Patients
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
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 3.000000 150.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.500000 75.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 2.750000 137.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 31.750000 1243.5200 39.1660
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 1 8.000000 3.5600 0.4450
Subtotal (Total Children Is Unduplicated) 16 54.000000 1983.9000 36.7389
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Total 54.500000 1983.9000 36.4018
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Number of Children (Unduplicated) With at Least One Service 16
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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 1 5.500000 275.0000 94.8200
27 49.000000 1708.9000 479.9600
Other 0 0.000000 0.0000 0.0000
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Total 28 54.500000 1983.9000 574.7800