CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 6 12.000000 444.0000 37.0000
Subtotal (Total Children Is Unduplicated) 6 12.000000 444.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 19.000000 1425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 5.500000 412.5000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 25 41.000000 2957.6000 72.1366
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 1.250000 62.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 60 284.000000 14225.0000 50.0880
OCCT-97530-OT SESSION BY LICENSED OT 3 14.000000 1000.1600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 4 10.950000 786.1500 71.7945
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 17.000000 1214.4800 71.4400
TRAV-TRAVS-Travel by mile 19 782.000000 348.1100 0.4452
Subtotal (Total Children Is Unduplicated) 93 1109.200000 17636.4000 15.9001
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Total 1162.200000 21038.0000 18.1019
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Number of Children (Unduplicated) With at Least One Service 113
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Center 54
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 1 1.000000 50.0000 50.0000
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
426 1161.200000 20988.0000 3175.3600
Other 0 0.000000 0.0000 0.0000
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Total 427 1162.200000 21038.0000 3225.3600