CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 109 111.750000 4134.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 19 15.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 127 495.000000 18315.0000 37.0000
Subtotal (Total Children Is Unduplicated) 127 621.750000 22449.7500 36.1074
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 8.000000 400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.666667 350.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 85 169.333333 12700.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 52.000000 3900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 50.000000 3750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 40.000000 2220.0000 55.5000
Subtotal (Total Children Is Unduplicated) 102 330.000000 23770.0000 72.0303
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 11.000000 550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 16.000000 160.0000 10.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 357.2000 71.4400
Subtotal (Total Children Is Unduplicated) 2 32.000000 1067.2000 33.3500
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Total 983.750000 47286.9500 48.0681
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Number of Children (Unduplicated) With at Least One Service 128
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Center 55
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 9 10.500000 388.5000 0.0000
P 411 552.000000 25790.0000 25790.0000
D 8 16.000000 1200.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 14.000000 1050.0000 0.0000
T 0 0.000000 0.0000 0.0000
429 391.250000 18858.4500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 864 983.750000 47286.9500 25790.0000