CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Payclass Filters:GR
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 226 99.000000 3663.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 87 58.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 543 1948.000000 72076.0000 37.0000
Subtotal (Total Children Is Unduplicated) 708 2105.250000 75739.0000 35.9763
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 98 178.000000 8900.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 75 69.000000 5175.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 99 105.000000 5827.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 47.000000 3525.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 3 3.000000 153.1500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 14 14.000000 714.7000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 4.000000 204.2000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 11 11.000000 561.5500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 52 54.000000 2756.7000 51.0500
Subtotal (Total Children Is Unduplicated) 276 490.500000 28166.3000 57.4236
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.500000 75.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 41 41.000000 2050.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 14 14.000000 700.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 141 142.000000 7100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 305 1878.000000 93900.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1030 7082.000000 70820.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 40 204.750000 14627.3400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 8.000000 457.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 32 113.500000 8108.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 19 133.500000 7630.8600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 74 388.844900 27779.0800 71.4400
TRAV-TRAVS-Travel by mile 51 12461.00000 5545.3500 0.4450
Subtotal (Total Children Is Unduplicated) 1090 22468.09490 238793.6700 10.6281
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Total 25063.844900 342698.9700 13.6730
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Number of Children (Unduplicated) With at Least One Service 1396
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Center 57
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 9 12.500000 462.5000 0.0000
S 153 348.750000 10266.7600 10266.7200
H 0 0.000000 0.0000 0.0000
T 3253 22233.344900 234744.2100 234744.2100
2761 2469.250000 97225.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6176 25063.844900 342698.9700 245010.9300