CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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 60 82.000000 3034.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 77 151.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 84 327.750000 12126.7500 37.0000
Subtotal (Total Children Is Unduplicated) 88 561.250000 15160.7500 27.0125
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 11.000000 825.0000 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 51 74.000000 4107.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 81.000000 6075.0000 75.0000
Subtotal (Total Children Is Unduplicated) 60 173.000000 11512.5000 66.5462
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 8.500000 425.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 10 9.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 19.000000 950.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 64 153.000000 1530.0000 10.0000
PHY-97110-PT SESSION BY LICENSED PT 1 4.000000 285.7600 71.4400
TRAV-TRAVS-Travel by mile 30 1038.000000 462.0200 0.4451
Subtotal (Total Children Is Unduplicated) 64 1231.500000 3652.7800 2.9661
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Total 1965.750000 30326.0300 15.4272
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Number of Children (Unduplicated) With at Least One Service 91
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Center 53
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 59 51.000000 1887.0000 0.0000
P 249 288.000000 13452.0000 13452.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 33 450.500000 427.7300 427.7300
T 32 242.500000 521.7600 521.7600
684 933.750000 14037.5400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1057 1965.750000 30326.0300 14401.4900