CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:OTHER
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 16 22.750000 841.7500 37.0000
Subtotal (Total Children Is Unduplicated) 16 22.750000 841.7500 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 12 24.000000 1200.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 10.000000 653.6200 65.3620
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 17.500000 1312.5000 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 15 26.500000 1470.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
Subtotal (Total Children Is Unduplicated) 43 88.500000 5424.3700 61.2923
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 124 170.500000 35.7200 0.2095
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 67.000000 3350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 51.250000 3661.3000 71.4400
Subtotal (Total Children Is Unduplicated) 125 290.750000 7189.9000 24.7288
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Total 402.000000 13456.0200 33.4727
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Number of Children (Unduplicated) With at Least One Service 181
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Center 09
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 560 377.750000 12598.1500 12598.1500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
23 24.250000 857.8700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 583 402.000000 13456.0200 12598.1500