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
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 12 23.750000 878.7500 37.0000
Subtotal (Total Children Is Unduplicated) 12 23.750000 878.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 11.500000 862.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.509777 338.2333 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 31.000000 1715.0000 55.3226
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 33.499970 2474.9978 73.8806
Subtotal (Total Children Is Unduplicated) 36 111.009747 7570.9811 68.2010
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 6.000000 439.9200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 0.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 129 628.250000 31412.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 3 10.000000 714.4000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 20.000000 1428.8000 71.4400
Subtotal (Total Children Is Unduplicated) 133 678.500000 34605.7400 51.0033
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Total 813.259747 43055.4711 52.9418
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Number of Children (Unduplicated) With at Least One Service 146
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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 0 0.000000 0.0000 0.0000
P 18 17.906640 821.2202 610.2200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 13 13.000000 650.0000 650.0000
T 11 11.000000 550.0000 550.0000
686 740.853107 39563.8709 0.0000
Other 30 30.500000 1470.3800 0.0000
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Total 758 813.259747 43055.4711 1810.2200