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
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 4 4.250000 157.2500 37.0000
Subtotal (Total Children Is Unduplicated) 4 4.250000 157.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 31.951503 2396.3604 74.9999
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 17.958300 1346.8700 74.9999
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 12.908400 968.1300 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 153.1500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 1.489800 76.0500 51.0471
Subtotal (Total Children Is Unduplicated) 36 72.308003 5291.6104 73.1815
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 130.2000 65.1000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 5 5.000000 250.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 7.000000 350.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 144.613016 10331.0900 71.4396
OCCT-97530HM-OT SESSION BY OT ASST 24 121.487069 6949.0600 57.2000
PHY-97110-PT SESSION BY LICENSED PT 19 77.316057 5550.4508 71.7891
PHY-97110HM-PT SESSION BY PT ASST 8 28.307920 1618.0800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 234.775493 16772.3588 71.4400
Subtotal (Total Children Is Unduplicated) 110 625.499555 42111.2396 67.3242
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Total 702.057558 47560.1000 67.7439
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Number of Children (Unduplicated) With at Least One Service 138
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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 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 9 16.990400 1274.2800 0.0000
T 0 0.000000 0.0000 0.0000
891 685.067158 46285.8200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 900 702.057558 47560.1000 0.0000